The Official Website of the US Training Council

American Heart Association Emergency Cardiovascular Care Program

Instructor Records Transfer Request

INSTRUCTIONS

If you are transfering FROM our Training Center to another...

then this form needs to be filled out as explained below.

*Your info & NEW Training Center info - highlighted in BLUE*

*Our Training Center info - highlighted in GREEN*

1. When a TC agrees to accept an Instructor, the TC Coordinator signs and sends this

form to the Instructor.

Our TC is willing to accept______Instructor's First & Last Name ____as an Instructor at

our facility.  We agree to keep and maintain all Instructor records in accordance with the

TC Agreement.

**********************Your NEW TC responsibility******************

Signature of TC Coordinator:__________________________________Date:____________

TC Address:________________________________________________________________

_____________________________________________________________________

TC Phone:                                                                    TC Fax

**********************************************************************

2. The Instructor completes the following information and sends it to the TC currently

holding his/her Instructor records.

I,__Instructor's Name_______________, authorize the transfer of my Instructor records

from: US Training Council TC to your NEW Training Center TC.

Instructor's home address:  Instructor's Address________________________________

_____________________________________________________________________

(Instructor's) Home phone                              (Instructor's) Work or mobile phone

Check discipline (s) for which you are requesting a records transfer

[] BLS [] Heartsaver  []ACLS []PALS  (check all that apply)

 

3. After verifying and completing this form, the Instructor's current TC transfers the

Instructor's record to the new TC.

The transferring TC must keep copies of all transferred records for 30 days.

 

4. The new TC Contacts the Instructor when the transfer is complete.

5. The TC Coordinator from the current TC signs and dates this form when the

records have been transferred.

Signature of TC Coordinator:__US Training Council TCC signature_DATE:_____

TC ADDRESS: 825 N. 300 W. Suite # C155, Salt Lake City, Utah, 84103

_____________________________________________________________________

Phone: 801.589.8290                                                               Fax: 801.776.1811

The instructions provided are to help with willing out this form.

If you have any questions about this form or process, please ask.


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