Minnesota State Colleges and Universities Multi-Regional Training Center. PALS Instructor Profile Forms

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1 Minnesota State Colleges and Universities Multi-Regional Training Center PALS Instructor Profile Forms Instructors: Please note: the PALS Instructor Profile Form should be used for all PALS Instructor Certification classes. Section A of this form should be re-submitted whenever any personal information in Section A changes or you may access your information and change online yourself. The completion of this form confirms that you have successfully completed your Instructor Course (initial or renewal) per the AHA standards. Members of the MnSCU MRTC, will receive an American Heart Association Instructor card (and Training Center Faculty card if applicable) and a packet of materials from the Training Center explaining course information, resources, and use of the instructor database. If you are not currently a member but would like to join our Multi-Regional Training Center, please see the Joining the MRTC page in this form, or call or Please note this form is also located on our website at: 1 Updated 3/14/2013 1

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3 PALS Instructor Profile Form Fire/EMS/Safety Center Multi-Regional Training Center 30 7 th St. E, Suite 350, Wells Fargo Place, St. Paul, MN Toll Free: Office: Fax: Section A: Instructor Profile Information-- This section is for information on instructors applying for membership or who are renewing their membership with the MnSCU MRTC. Please complete and return Section A any time this information changes or update on your database information page. Applicants Name: MRTC Member # Home Address: AHA ID # City: State: Zip Code: County of Residence: Address* *Must have an address Telephone Numbers: Home Work Employers Name: Work Address: City: State: Zip Code: Fax: Year you started teaching PALS: Specialized Health Care Qualifications (R.N., L.P.N., EMT, EMT-P, etc.) Last Date of last Renewal: Instructor Name: Core Instructor Course completion form attached if new Instructor: Updated 3/14/2013 3

4 PALS Instructor/Experienced Instructor Documentation Record Section B INSTRUCTIONS: Submit this entire form as documentation that the applicant has successfully completed the Instructor course. Instructors must retain copies of all provider documents (i.e. roster forms, test scores, skill checklists) for a minimum of three years. Requesting AHA Instructor Card for: Instructor (Initial) Instructor Renewal Training Center Faculty Written Test Score(s): Skills: Pass Fail Remediate Remediation Plan: Date Monitored Teaching: By whom: Attach Monitoring Form (Required and must accompany profile form). Minimum Teaching Requirements: Note: Re-Certifying Instructors must teach/assist a minimum of four provider classes in two years. MRTC Faculty must teach/assist in four classes which include one Instructor course. *The Core Instructor Course counts as one provider course.* Instructors: If entered on line here: then you do not need to list below. Otherwise please list minimum required dates taught (if not online): Provider: 1) Date: 2) 3) 4) Course: # Students: MRTC Faculty: If entered on line here: -OR- then you do not need to list below. Otherwise please list minimum required dates taught (if not online): Instructor 1) Date: 2) 3) 4) Courses: Course: # Students: To enter more classes online go to click on MRTC then follow printable directions under Instructor Database or CPR Reporting in Quick Links then click on Entering Courses Online. 4 Updated 3/14/2013 4

5 Section C Skills Sign-Off Form I certify that has successfully completed the PALS Instructor Course and the PALS practical and written evaluations in accordance with the standards of the American Heart Association and the MnSCU MRTC. National/Regional Faculty/: Course Director Signature Print Name Medical Supervision*: Print Name *If not teaching in the classroom, list name of physician available for consult. Date(s) of course: Course Location: 5 Updated 3/14/2013 5

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13 Joining/Re-aligning with the MnSCU Multi-Regional Training Center 1) New/Renewing Instructors: Mail this completed Instructor Profile Packet all pages, along with the bi-annual membership dues. Your card and materials will be mailed upon receiving this AHA required information. 2) Payment of the biennial $25.00 membership dues by one of three ways: a. Check (please make checks payable to MnSCU MRTC) b. Purchase Order (include PO # here: ) (Must have Credit Application for invoicing/po if not a state agency call for application). c. Credit Card (Master card and Visa Only) pay dues online at: MRTC Online (No S/H or Sales Tax) PER CREDIT CARD REGULATIONS WE CAN ONLY ACCEPT TRANSACTIONS THRU OUR ONLINE ORDERING SYSTEM. You will receive an notification. I agree to adhere to American Heart Association and Minnesota State Colleges and Universities/Multi-Regional Training Center policies, using appropriate AHA materials and issuing certification cards. Print Name Signature Date ****************************************************************************** MRTC Office Use Only: Form of Payment: Check # Name on Check Cash Credit Card (Type): Date routed to MRTC Support: Initials: Date Receipt sent: Multi-Regional Training Center 30 7 th St., E., Suite 350, Wells Fargo Place, St. Paul, MN Toll Free: Office: Fax: Updated 3/14/