Home 9 RI – AHA BLS Provider Roster Submission

URMC - BLS Provider Course Roster

Step 1 of 2

Select type of course held.*BLS CourseBLS Renewal CourseHeartCode BLSBLS Instructor Course

Lead Instructor*

Lead Instructor ID# and Exp. Date*

Lead Instructor Email*

Lead Instructor Phone*

Course Location*

Course Address*

Course City State ZIP*

Course Start Date*

Course End Date*

Total Hours*

Course Start Time (24 hour time)*

Course End Time (24 hour time)*

Student-Manikin Ratio*

Assisting Instructors

1. Name & Instructor ID #

Card Exp. Date

5. Name & Instructor ID #

Card Exp. Date

2. Name & Instructor ID #

Card Exp. Date

6. Name & Instructor ID #

Card Exp. Date

3. Name & Instructor ID #

Card Exp. Date

7. Name & Instructor ID #

Card Exp. Date

4. Name & Instructor ID #

Card Exp. Date

8. Name & Instructor ID #

Card Exp. Date

Course Participants

Total Course Participants (If the number of participants is greater than 30, evenly divide between multiple rosters.)

This is the total number of cards for which you will be charged.

1. First & Last Name

Telephone

Complete / Incomplete

Test Score

2. First & Last Name

Telephone

Complete / Incomplete

Test Score

3. First & Last Name

Telephone

Complete / Incomplete

Test Score

4. First & Last Name

Telephone

Complete / Incomplete

Test Score

5. First & Last Name

Telephone

Complete / Incomplete

Test Score

6. First & Last Name

Telephone

Complete / Incomplete

Test Score

7. First & Last Name

Telephone

Complete / Incomplete

Test Score

8. First & Last Name

Telephone

Complete / Incomplete

Test Score

9. First & Last Name

Telephone

Complete / Incomplete

Test Score

10. First & Last Name

Telephone

Complete / Incomplete

Test Score

11. First & Last Name

Telephone

Complete / Incomplete

Test Score

12. First & Last Name

Telephone

Complete / Incomplete

Test Score

13. First & Last Name

Telephone

Complete / Incomplete

Test Score

14. First & Last Name

Telephone

Complete / Incomplete

Test Score

15. First & Last Name

Telephone

Complete / Incomplete

Test Score

16. First & Last Name

Telephone

Complete / Incomplete

Test Score

17. First & Last Name

Telephone

Complete / Incomplete

Test Score

18. First & Last Name

Telephone

Complete / Incomplete

Test Score

19. First & Last Name

Telephone

Complete / Incomplete

Test Score

20. First & Last Name

Telephone

Complete / Incomplete

Test Score

21. First & Last Name

Telephone

Complete / Incomplete

Test Score

22. First & Last Name

Telephone

Complete / Incomplete

Test Score

23. First & Last Name

Telephone

Complete / Incomplete

Test Score

24. First & Last Name

Telephone

Complete / Incomplete

Test Score

25. First & Last Name

Telephone

Complete / Incomplete

Test Score

26. First & Last Name

Telephone

Complete / Incomplete

Test Score

27. First & Last Name

Telephone

Complete / Incomplete

Test Score

28. First & Last Name

Telephone

Complete / Incomplete

Test Score

29. First & Last Name

Telephone

Complete / Incomplete

Test Score

30. First & Last Name

Telephone

Complete / Incomplete

Test Score

Upload Supporting Documents (PDF file format only)

Pre-submission Check List

Select the type of roster you are submitting.*I have confirmed this roster is complete including: Assisting Instructors, Participants Information, and Test Scores.I am submitting an offline PDF Roster and have verified it is in the upload list of supporting documents.

All BLS Courses - I have verified the participants' skill sheets are in the upload list of supporting documents.*YesN/A

BLS Course & BLS Renewal - I have verified the participants' exam answer sheets are in the upload list of supporting documents.*YesN/A

BLS Renewal Only - I have verified the participants' proof of having an AHA BLS Provider card in the upload list of supporting documents.*YesN/A

Submitters Information

Your Name*

Email address you wish to receive proof of paperwork submission.*

Message or additions information. (optional)

Please only click the Submit Course Roster button once. Depending on the supporting paperwork file size you are submitting, it may take up to 30 seconds for you to receive acknowledgement that the paperwork was submitted and to be provided a download link to your official course roster.

Continue to Step Two

After you have submitted your BLS Provider Roster and received the “Thank you for uploading your AHA BLS Provider Roster.” message, click on the Purchase BLS Provider eCards button to continue.

Purchase BLS Provider eCards

URMC - BLS Provider Course Roster

Continue to Step Two

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