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VANDERBILT UNIVERSITY MEDICAL CENTER

Vanderbilt Resuscitation Program

ACLS Course Approval Request

COURSE DIRECTOR NAME: 
 
COURSE DIRECTOR PHONE: 
 
COURSE DIRECTOR EMAIL: 
 
ASSISTING INSTRUCTOR(S): 
COURSE TYPE:
 
ACLS Renewal
ACLS Provider
 
NUMBER OF STUDENTS: 
 
COURSE START DATE (mm/dd/yy):                           
COURSE START TIME (hh:mm AM/PM): 
 
COURSE END DATE (mm/dd/yy):                          
COURSE END TIME (hh:mm AM/PM): 
 
COURSE LOCATION: 
I am a designated ACLS Course Director with the Resuscitation Program.
YES NO
I understand that I must be physically present for the entire course for which I am seeking approval.
YES NO
 

 

This page was last updated November 14, 2012 and is maintained by Sarah Bishop