Application Checklist

Transcription

1 Application Checklist Complete this checklist prior to returning your application to become an affiliated training site. Incomplete applications will not be considered. Completed Application Form Copy of insurance certificate showing coverage for your training site (not individual(s)) for professional indemnity insurance * Copy of insurance certificate showing coverage for your training site (not individual(s)) for public liability insurance * Copy of organisation s certificate of incorporation or registration of business name Equipment List Refer to point 4.1 on application form AV Equipment List Refer to point 4.2 on application form List of extra instructors if more than 6 Refer to point 1.1 on application form * Insurance coverage must in the name of the training site applying for affiliation thereby covering all instructors/individuals that may work through the site. Coverage for individual(s) is not sufficient. Where a training site does not already have such insurance in place Irish Heart will accept a written quotation for the type of insurance that is proposed to be purchased to be assessed with the application. The quotations must be less than one month old. If the application is then approved no contract would be issued until Irish Heart has received written proof that the necessary insurances are in place. IHF Application Form for Affiliation to CPR & ECC Training Programme 2018, Page 1 of 9

2 Details of Proposed Training Site: Please complete this form using block capital letters. Illegible writing may result in your form being returned. Name of Organisation: Address: Contact Phone Number: Contact Address: Website (if applicable): Description of Type of Organisation: Date of Foundation: Name: Job Title: Contact Phone: Contact Instructor Qualification(s): Training Site Coordinator: Please briefly indicate the need for your organisation to become a training site affiliated to Irish Heart s CPR & ECC Training Programme: IHF Application Form for Affiliation to CPR & ECC Training Programme 2018, Page 2 of 9

3 1. Instructors: 1.1 Please list all current Heartsaver, BLS and ACLS instructors who will train through this site and note where instructors also hold CFR Instructor Certification: * Name: Contact Phone Number: Discipline(s) in which instructor is certified as an IHF Instructor: * If you have more instructors please enclose separate documentation listing all instructors which will train through this site. 1.2 Please describe how your training site will ensure instructors adhere to all IHF/AHA/PHECC policies and procedures in regard to courses conducted through your training site: 2. Courses: 2.1 Please give a brief background to the type of candidates your training site is aiming to train: 2.2 Will your training site be providing training outside of your organisation? (Please circle) IHF Application Form for Affiliation to CPR & ECC Training Programme 2018, Page 3 of 9

4 2.3 How many courses are you planning to teach through the site each year? Course: CPR for Family & Friends Heartsaver CPR AED CFR Community BLS for Healthcare Provider CFR Advanced ACLS Provider ACLS EP Provider Number of courses: 2.4 How many people (approx) do you plan to train through your training site each year? Course: CPR for Family & Friends Providers Heartsaver CPR AED Providers CFR Community Providers BLS Healthcare Providers CFR Advanced Providers ACLS Providers ACLS EP Providers Number of providers: 2.5 Please explain how you calculated the answers to questions 2.3 and 2.4 above: 2.6 Please estimate the student to instructor ratio your site plans to use: 2.7 Please describe how you plan to evaluate each course and gain student feedback: IHF Application Form for Affiliation to CPR & ECC Training Programme 2018, Page 4 of 9

5 2.8 Please list any other non IHF courses your site offers/plans to offer: 3. Record Keeping: 3.1 Who will have access to the files and successful course completion cards? Name(s) Title(s) 3.2 Training Site will be able to issue course cards within 30 days of course completion? (Please circle) 3.3 Please indicate the length of certification for cards when issued. 3.4 Training Site will submit all required training records and reports to IHF by stated deadlines? (Please circle) 3.5 Please describe the system the training site plans to use to document course training records IHF Application Form for Affiliation to CPR & ECC Training Programme 2018, Page 5 of 9

6 4. Facilities & Equipment: 4.1 Please attach a separate list of all functioning training equipment the training site owns including manikins, AED trainers, etc. 4.2 Please attach a separate list of all functioning AV equipment the training site owns. 4.3 Does your training site have space to conduct courses? (Please circle) 4.4 If your site does not have space to conduct courses please explain where courses will be held 4.5 Does your training site have the following? (Please circle) Computer system to record training records? Computer with internet access? Computer with access? Space to retain hard-copy training records? 4.6 Will the training site be supplying all candidates with the appropriate AHA/IHF/PHECC textbook/materials? (Please circle) 4.7 Does your site have a manikin hygiene policy? (Please circle) 4.8 Does your site have a written Health & Safety policy? (Please circle) IHF Application Form for Affiliation to CPR & ECC Training Programme 2018, Page 6 of 9

7 Please send this completed application form and all required supporting documents to: CPR & ECC Training Department Irish Heart Foundation Rathmines Lower, Rathmines, Dublin 6 D06 C780 Please refer to the Application Checklist to ensure you include all relevant supporting documents with your application. IHF Application Form for Affiliation to CPR & ECC Training Programme 2018, Page 7 of 9