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:__________________________________