American Heart Association Training Center

1818 Brigham Young

Casper, WY 82604

307-265-2131

Revised 8/2008

AHA Instructor Training Site Agreement Form

Issue Date: ______ Expiration Date: ______
This is an agreement between ______, designated as anInstructor Training Site and Healthy U Educators, a contracted training center with the American Heart Association (AHA).
Check all that apply:
____Basic Life Support (BLS) Instructor ____Advanced Cardiac Life Support(ACLS) Instructor
____Heartsaver (HS) CPR Instructor ____Pediatric Advanced Life Support(PALS) Instructor
This agreement is valid from issue date of the AHA Instructor card through the renewal date. The Instructor will conduct all BLS, ACLS and PALS courses: Instructor, Course Director, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Healthcare Provider, Heartsaver CPR, AED, CPR in Schools, First Aid, Pediatric First Aid, CPR Anytime, Family & Friends, in accordance with standards and guidelines set forth by the AHA ECC Sub-committee for the Colorado & Wyoming region, using the following criteria:
CRITERIA
  • Follow ALL of the most current AHA guidelines.
  • Maintain a current Instructor status throughout this agreement.
  • Maintain a copy of all rosters for classes taught for a period of three (3) years.
  • Send the original rosters and monitoring forms within 30 days of the course.
  • Issue appropriate documentation of completion/participation to each student.
  • Ensure all training will be done in an appropriate facility with all of the necessary equipment present.
  • Formally acknowledge that all fees for BLS, FA, ACLS and PALS training do not represent revenue to the AHA.

PROBLEM SOLVING
Incomplete paperwork and classes taught improperly will result in the following actions:
  1. Verbal communication to resolveissues.
  2. Written action plan to resolve issues with possible suspension and/or warning of termination.
  3. Possible termination of Instructor privileges with Healthy U Educators
This is a two-year agreement and will be terminated on and no later than the date noted on the Instructor card. There is NO grace period for expiration. Healthy U Educatorsreserves the right to terminate this agreement at anytime if Training Center policies and/or AHA standards and guidelines are not met.
As an Instructor, I will adhere to the above criteria. I understand and agree to follow all of the above criteria and non-compliance may result in termination of this agreement.
______Instructor signature Date TC Coordinator signature Date
______Karen Merback ______
Instructor printed name TC Coordinator printed name