AED test sheet - Lifesaving Society
Transcription
AED test sheet - Lifesaving Society
1 2 Result Y/M/D Sex M 1 One and Two Rescuer AED Side 1: Please print each candidate's name and contact information legibly. AED Knowledge: use and operation CPR prerequisite checked Date of Birth Lifesaving AED F Name Address Postal code City E-mail Telephone Sex M 2 F Name Address Postal code City Telephone E-mail Sex M 3 F Name Address Postal code City E-mail Telephone Sex M 4 F Name Address Postal code City E-mail Telephone Sex M 5 F Name Address Postal code City E-mail Telephone Sex M 6 F Name Address Postal code City E-mail Telephone Check box if there are more candidates on the reverse side of this page. This test sheet is page ___ of ___ pages. 9 Satisfactory Performance Instructor Information F Fail Total Pass for Course Total Fail for Course Exam Information Exam Date: Instructor's Name E-mail ( ) MM DD Facility name Telephone Exam fees attached ( ) Telephone Awards information Signature Payment Information Awards issued by affiliate Awards not issued Exam fees not attached Examiner Information Send invoice or receipt to ( Affiliate ) Telephone Examiner's Name ID# E-mail Address City YY ID# Province Postal Code ( ) Telephone Return completed test sheet to the Lifesaving Society Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail. Signature 1 2 Result Y/M/D Sex M 7 One and Two Rescuer AED Side 2: Please print each candidate's name and contact information legibly. AED Knowledge: use and operation CPR prerequisite checked Date of Birth Lifesaving AED F Name Address Postal code City E-mail Telephone Sex M 8 F Name Address Postal code City E-mail Telephone Sex M 9 F Name Address Postal code City E-mail Telephone Sex M 10 F Name Address Postal code City E-mail Telephone Sex M 11 F Name Address Postal code City E-mail Telephone Sex M 12 F Name Address Postal code City E-mail Telephone Check box if there are more candidates on the reverse side of this page. This test sheet is page ___ of ___ pages. 9 Satisfactory Performance F Fail Total Pass for Course Total Fail for Course Exam Information Exam Date: YY ( Affiliation MM DD ) Telephone Facility name Please complete Instructor, Awards and Payment information sections on Side 1 of test sheet. Host name, Exam information, and Examiner sections must be completed on both sides 1 and 2 of the test sheet. Veuillez s'il vous plaît remplir les informations pertinentes dans les sections concernant les moniteurs, les certificats et le mode de paiement au recto de la feuille. Il faut inscrire les renseignements concernant l'examen et l'évaluateur sur les deux côtés de la feuille d'examen. ( ) Telephone Awards information Awards issued by affiliate Awards not issued Examiner Information Examiner's Name ID# E-mail ( ) Telephone Return completed test sheet to the Lifesaving Society Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail. Signature