2010_roster

EMS Safety Course Roster: Instructions for Use

The EMS Safety course roster is used for all provider training courses. Sign and date each page where indicated. Rosters, along with all course records, must be maintained by the instructor for 3 years and provided to EMS Safety upon request. Rosters can be handwritten or typed in and printed. Ensure that rosters are compete and legible.

1.

Roster Page 1: Course Information a. Instructor Information  Instructor: Name of the Lead Instructor for the course  Instructor #: EMS Safety Instructor Number for Lead Instructor  Instructor Phone #: Primary contact phone number for Lead Instructor  Date of Training: Course start date

b.

 Assisting Instructor: Name of secondary Instructor assisting with class  Instructor #: EMS Safety Instructor Number for Assisting Instructor Course Information  Business/Organization Name: Name of business or organization where course was held. May be non-applicable, residence, or ‘community class.’  Address of Course: Location where course was held  City, State, Zip: Location where course was held  Contact Name: Person in charge of course from Business or Organization; may not apply to all courses

c.

 Title: Title of Course Contact  Phone Number: Phone number of Course Contact Course Type

d.

 Check any that apply; use separate rosters for additional course dates.

Student Information  Name: As student wants it to appear on card  Phone: Primary contact phone number for student  Address: Work or home address  Email: Primary email address; used for card expiration reminders

2.

 Card Number: Unique control number located on provider card Roster Page 2: Skills Summary a. Course Information  Instructor: Name of the Lead Instructor for the course (same as page 1)  Instructor #: EMS Safety Instructor # for Lead Instructor (same as page 1)  Date of Training: Start date of course (same as page 1) b.

 Course Address: Location of course (same as page 1) Student Completion Information  Student Name: Should correspond with names on page 1  Skill Check: Check each skill that student has completed successfully  Exam Scores: Enter exam scores from answer sheet Questions?

Contact us by phone at (800) 215-9555, via email at info@emssafety.com, or chat with us online at www.emssafety.com.

Training Course Roster

Instructor

Instructor #

Assisting Instructor

Instructor #

Instructor Phone #

Date of Training

Course Information: Business/Organization Name (if applicable)

Address of Course

City, State, Zip

Contact Name (if applicable)

Title

Phone Number

Course Type: (Check all that apply) Adult CPR

Child CPR

Infant CPR

Basic First Aid

CPR/AED

CPR/AED for Professional Rescuers

Bloodborne Pathogens

Other: _______________________

Name (Print Clearly) 1 2 3 4 5 6 7 8 9 10 11 12

Phone #

Address (Street, City, State, Zip)

Advanced First Aid

Email Address

Card #

I hereby state that the above course was taught according to the standards and guidelines set forth by EMS SAFETY SERVICES. All certified students met the minimum requirements for passing. I understand that I am responsible for maintaining the roster and course records for at least three years.

Instructor Signature:________________________________________________

Date:__________________________________

Skills Summary

Instructor

Instructor #

Date of Training

Course Location

Using an AED

Student Name

Adult CPR

Child CPR

Glove Removal

Infant CPR

Adult/Child Choking Care

Infant Choking Care

First Aid Assessment

Bleeding and Bandaging

Epinephrine AutoInjector

CPR Exam Score

First Aid Exam Score

1

2

3

4

5

6

7

8

9

10

11

12

[Type text] [Type text] Instructor Signature:________________________________________________

[Type text] Date:__________________________________