Photo: YES or NO. Skills Performed Approved: YES or NO. Current Provider Certification. Affiliation Agreement. Candidate Application

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1 Name: Photo: YES or NO Skills Performed Approved: YES or NO Current Provider Certification Expires: Affiliation Agreement Candidate Application Core Certification AHA Update: Instructor Card Expires: Last Monitor Next Monitor Due Date TCF Certification Expires: Renewal Packet Heartsaver BLS ACLS PALS Notes:

2 Kentuckiana CPR & Safety Training Center Instructor Data Sheet Name Instructor number Address City State Zip code Home Phone_( ) Cell Phone _( ) Work Phone _( ) Address What is the best way to contact you? Liscensure/ Credential Instructor status Heartsaver BLS TCF RF NF ECC RCM ACLS TCF RF NF ECC RCM PALS TCF RF NF ECC RCM I will update any change in contact information within 30 days of the change. Instructor Signature Date

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4 Kentuckiana CPR & Safety Training Center Instructor Affiliation Agreement Name Date Address City State Zip code Cell Phone _( ) Home Phone_( ) Address Employer Instructor Status (Check all that apply) Heartsaver Instructor BLS Instructor BLS Instructor Trainer ACLS Instructor ACLS Instructor Trainer PALS Instructor PALS Instructor Trainer As an American Heart Association Instructor affiliated with Kentuckiana CPR & Safety Training Center, I agree to the following: I will follow the guidelines, policies and procedures of the American Heart Association and the Kentuckiana CPR & Safety Training Center. I have read the Policies and procedures of the TC and acknowledge what is expected of me as an instructor. My signature below signifies my agreement to follow these guidelines at all times. I understand My alignment will not be granted until I have completed a phone or video conference with the Training Center Coordinator of Kentuckiana CPR. I have will update any change in contact information or Instructor status by repeating this affiliation agreement and submitting it to Kentuckiana CPR & Safety Training Center within 30 days of the change. Instructor Signature Date Tony Huey Kentuckiana CPR Training Center Coordinator Date Received

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6 Kentuckiana CPR & Safety Training Center Monitor Directions Form understands he/she is required to teach a minimum, of two to a maximum of four classes as the lead instructor to fulfill the monitoring requirement. After 4 unsuccessful attempts he /she understand he /she will be responsible for the cost of attending another Instructor course should he /she desire to continue. He /she understands they have 6 months after the Instructor Course to complete the monitoring steps. If it is not completed within that time frame he/she will be responsible for the cost of attending another instructor course. It is the student and TCF responsibility to coordinate together to schedule monitoring. TCF are required to be present at my class in which I monitor. Your first opportunity to monitor is Your 2nd opportunity to monitor is Additional monitoring was required on Additional monitoring was required on He /she must contact the Training Center Coordinator at upon successful completion of his/her monitoring sessions to schedule a phone conference with the Training Center Coordinator. This phone conference is mandatory and must be completed before alignment will be granted. Instructor candidate signature Date

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9 ECC Course Evaluation Please answer the following questions about your Instructor. My Instructor: 1. Provided instruction and help during my skills practice session 2. Answered all of my questions before my skills test 3. Was professional and courteous to the students Please answer the following questions about the course content. 1. The course learning objectives were clear. 2. The overall level of difficulty of the course was a. Too hard b. Too easy c. Appropriate 3. The content was presented clearly. 4. The quality of videos and written materials was a. Excellent b. Good c. Fair d. Poor 5. The equipment was clean and in good working condition. Please answer the following questions about your skill mastery. 1. The course prepared me to successfully pass the skills session. 2. I am confident I can use the skills the course taught me. c. Not sure 3. I will respond in an emergency because of the skills I learned in this course. c. Not sure 4. I took this course to obtain professional education credit or continuing education credit. Optional questions: Have you previously taken this course via another method, such as in a classroom or online? Which learning method do you prefer and why? Were there any strengths or weaknesses of the course that you would like to comment on? What would you like to see in future courses developed by the AHA? Upon completion: Please this form to or mail to Kentuckiana CPR 280 Missouri Ave Suite E Jeffersonville, IN Instructor or Training Center KJ0920 HC 5/ American Heart Association