American Heart Association Emergency Cardiovascular Care Program

Airway Management Course Roster Form

Course Information

This course included the following modules Course Facilitator___________________________________________

Bag-Mask Ventilation and Airway Adjuncts (required)

† Laryngeal Mask Airway (LMA) (optional)
† Esophageal-Tracheal Combitube (optional)
† Endotracheal Tube (ET Tube) (optional)
† Impedance Threshold Device (ITD) (optional)
Course Location___________________________________________
Address _________________________________________________
City, State ZIP ___________________________________________

Course Start Date/Time_______________ Course End Date/Time_________________ Total hours of Instruction __________

Assisting Facilitators
Name Module / Station Name Module / Station
1. 5.
2. 6.
3. 7.
4. 8.
I verify that this information is accurate and truthful, and that it may be confirmed. This course was taught in accordance with AHA guidelines.

____________________________________________ _______________________________________________
Signature of Course Facilitator Date

© 2007 American Heart Association Airway Course Roster 2007, page 1

DATE_________________ COURSE: Airway Management COURSE Facilitator __________________________________
Course Participants
NAME Remediation/
Complete/ Exam
Please PRINT as you wish your name to Address Telephone Date
Incomplete Score
appear on your card. Completed
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Airway Course Roster 2007, page 2