ACLS NEW AFFILIATION
1. ____MTN AFFILIATION FORM
2. ____EQUIPMENT LIST (Signed by the Program Director and Program Administrator)
3. ____INSTRUCTOR LIST
4. ____SATELLITE LIST (If applicable)
5. ____AGENDA FOR EACH COURSE TAUGHT
6. ____PROGRAM DIRECTOR NOMINATION FORM
7. ____TRAINING SITE FACULTY NOMINATION FORM (Program Director only)
8. ____MTN CURRICULUM VITAE FORM (Program Director only)
9. ____COPY OF INSTRUCTOR ESSENTIALS COURSE CERTIFICATE (Program Director only)
10. ____COPY OF AHA GUIDELINES UPDATE CERTIFICATE (Program Director only)
11. ____COPY OF PROGRAM DIRECTOR’S SIGNED TSF OR ACLS INSTRUCTOR CARD (Front and Back)
12. ____PROGRAM ADMINSTRATOR APPOINTMENT FORM
ALL FORMS MUST BE TYPED – MTN WILL NOT ACCEPT HANDWRITTEN FORMS
July 17
MILITARY TRAINING NETWORK (MTN)
ALCS AFFILIATION/RE-AFFILIATION REQUEST FORM
Unit
Name
Program
Administrator
Program
Administrator Work
Phone Number
Mailing Address for MTN Correspondence:
Unit/Office:
Program Director
Shipping/Street Address:
City, State, Zip:
Program Director
Work Phone Number
Fax Number
PD TSF Card Exp
Date
Program Administrator
Email Addresses:
Program Director
Training Projection
Estimate the number of students to be trained annually.
ACLS Provider
ACLS Instructor
Training Site Faculty (TSF)
Commanding Officer Contact Information
Commanding Officer(Rank/First/Last Name)
Commanding Officer Official Mailing Address
Work Phone Number
Commanding Officer Email Address
I CERTIFY THAT THE PROGRAM ADMINISTRATOR AND THE PROGRAM DIRECTOR
WILL ADMINISTER THE BLS PROGRAM IN ACCORDANCE WITH MTN GUIDELINES.
IN ADDITION, I VERIFY THAT ALL EQUIPMENT IS AVAILABLE TO CONDUCT
TRAINING.
_________________________
Program Director Signature
____________________________
Commanding Officer Signature
ALL FORMS MUST BE TYPED – MTN WILL NOT ACCEPT HANDWRITTEN FORMS
July 17
REQUIRED EQUIPMENT LIST
ADVANCED CARDIAC LIFE SUPPORT
Equipment
ACLS Provider Manual
ECC Handbook (optional)
ACLS Instructor Manual and Lesson Maps
TV with DVD Player or Computer with Projector
Course DVD
Adult Manikin with Shirt
Adult Airway Manikin
Stopwatch
AED Trainer with Adult Training Pads
Adult Pocket Mask
1-Way Valve
Bag-Mask, Reservoir and Tubing
Oral and Nasal Airways
Water-Soluble Lubricant
Nonrebreathing Mask
Waveform Capnography
ECG Simulator/Rhythm Generator
Electrodes
Monitor Capable of Defibrillation/Synchronized
Cardioversion/TCP
Pacing
Pads, Defibrillator Pads, or defibrillator gel
Spare ECG Paper
Epinephrine
Atropine Sulfate
Amiodarone (or Lidocaine)
Adenosine
Vasopressin
Saline Fluid Bags/Bottles
IV Pole
Sharps Container (If Using Real Needles)
Advanced Airway Skills (optional)
Manikin Cleaning Supplies
_____________________________
Program Director Signature
Requirements
______________________________
Commanding Officer Signature
ALL FORMS MUST BE TYPED – MTN WILL NOT ACCEPT HANDWRITTEN FORMS
July 17
# on Hand
1/ Student and Instructor
1/ Student and Instructor
1 / Instructor
2 / Course
2 / Course
1 / Every 3 Students
2 / Every 12 Students
1 / Instructor
1 / Every 3 Students
1 / Every 3 Students or 1 / Student
1 / Student
1 / Every 3 Students
1 / Set/Each Station
1 / Station
1 / Every 3 Students
1 / Course
1 / Station
1 / Station
1 / Station
1 / Station
1 / Station
1 / Station
1 / Station
1 / Station
1 / Station
1/Station
1 / Station
1 / Station
1 / Station
1 / Station
Varies
MILITARY TRAINING NETWORK
ACLS INSTRUCTOR LIST
Date:
1.
2.
3.
4.
List all Instructors including satellite personnel
Instructor to TSF ratio is 15:1
Number of Instructors
Number of TSF:
Send MTN a copy of each TSF nomination form/ensure MTN has TSF form(s) on file.
Fill in the expiration (exp) date for all ACLS instructors and submit copies with the annual
report NLT 30 Sep.
Name (Last, First, MI)
Rank, Branch of Service, Corps
Professional
Licensure
(MD, DO,
CRNA, RN,
EMT, etc.)
Instructor Card
Exp Date
TSF Card
Exp Date
ALL FORMS MUST BE TYPED – MTN WILL NOT ACCEPT HANDWRITTEN FORMS
July 17
SATELLITE LIST
All satellites must be in the same geographic area (within 100 mile radius) as the Training Site.
Satellite Name
Complete Address
Phone Number
ALL FORMS MUST BE TYPED – MTN WILL NOT ACCEPT HANDWRITTEN FORMS
July 17
(INSERT UNIT NAME)
ACLS Instructor Course Agenda
Time
Lesson
Event
0735-0745
Lesson 1
ACLS Instructor Overview and Organization
0745-0800
Lesson 2
Conducting ACLS Learning Stations
0800-0830
Lesson 3
Learning Station: Management of Respiratory
Arrest
0830-0900
Lesson 4
Learning Station: CPR and AED
0900-0915
Break
0915-1000
Lesson 5
Learning Station: Bradycardia/PEA/Asystole
1000-1045
Lesson 6
Learning Station: Tachycardia/Stable and Unstable
1045-1130
Lesson 7
Learning Station: Cardiac Arrest (VF/Pulseless VT)
1130-1230
Lunch
1230-1245
Lesson 8
Review: Debriefing
1245-1255
Lesson 9
Video-Driven Learning Stations
1255-1340
Lesson 10
ACS/Stroke Learning Stations Practice
1340-1400
Break
1400-1415
Lesson 11
ACS Skills Testing Stations
1415-1500
Lesson 12
Testing Station: Megacode
1500-1530
Lesson 13
Training Center-Specific Policies
1530-1600
Lesson 14
Written Test
1600-1615
Lesson 15
Summary/Course Evaluation
Adapted From 2013 AHA ACLS Faculty Guide
(INSERT UNIT NAME)
ACLS PROVIDER COURSE
Day 1
8:30 - 8:35
8:35 - 8:40
8:40 - 9:00
Welcome/Introductions
Lesson 1 – ACLS Course Overview/Organization
Lesson 2 – BLS and ACLS Surveys
Divide class into 2 Groups
9:00 - 9:45
9:45 - 10:00
Lesson 3
Management of Respiratory Arrest
Learning and Testing Station
Group 1
Break
Lesson 4
CPR and AED Practice and Testing
Station
Group 2
Break
10:00 - 10:45
Group 2
Group 1
One large group
10:45 - 11:10
Lesson 5 – The Megacode and Resuscitation Team Concept
Divide class into 2groups
11:10 - 12:40
12:40 - 13:25
13:25 - 14:55
14:55 – 15:10
Lesson 6
Cardiac Arrest (VF/Pulseless VT) Learning Station
Group 1
Lunch
Group 2
Lessons 7 and 8
ACS and Stroke Learning Station
Group 2
Lunch
Group 1
Break
Divide class into 2 groups
Lesson 9
Bradycardia/Asystole/PEA
Learning Station
15:10 - 15:55
15:55 - 16:40
16:40
Group 1
Group 2
Lesson 10
Tachycardia, Stable and Unstable
Learning Station
Group 2
Group 1
End of Day 1
Day 2
Divide class into 2 groups
8:30 - 10:05
10:05 - 10:20
Lesson 11
Putting It All Together
Learning Station
Group 1
Lesson 11
Putting It All Together
Learning Station
Group 2
Lesson T3-5
Mega Code Test
Group 1
Lesson T3-5
Mega Code Test
Group 2
Break
Divide class into 2 groups
10:20 - 11:20
One large group (as students finish Megacode test)
11:20 - 12:05
Lesson T6 - 7 - Written Test
12:05
Class Ends/Remediation
ADAPTED FROM THE AHA 2011 ACLS MANUAL
(INSERT UNIT NAME)
ACLS UPDATE COURSE
8:30 - 8:35
8:35 - 8:40
8:40 - 9:05
9:05 - 9:25
Welcome/Introductions
Lesson 1 - ACLS Course Overview/Organization
Lesson 2 - ACLS Science Overview Video
Lesson 3 - BLS and ACLS Surveys (Lesson Maps ACLS-U 3A-B)
Divide class into 2 groups
9:25 - 9:55
9:55 - 10:25
Lesson 4
Lesson 5
(Lesson Maps ACLS-U 4A-B)
(Lesson Maps ACLS-U 5A-B)
Bag- Mask Ventilation Testing Station
Group 1
Group 2
CPR /AED Testing Station
Group 2
Group 1
One Large Group
10:25 - 10:40 Break
10:40 - 11:05 Lesson 6 - The Megacode and Resuscitation Team Concept
Divide Class into 2 Groups
11:05 - 12:30
Lesson 7
Lesson 7
(Lesson Maps ACLS-U 7A)
(Lesson Maps ACLS-U 7A)
Putting It All Together Learning
Station
Group 1
Putting It All Together Learning
Station
Group 2
12:30 – 13:15 Lunch
Divide Class into 2 Groups
Mega Code Test
13:15 -14:15
Group 1
One large group (as students finish Megacode test
14:15 - 14:45 Lesson T6 - Written Test
14:45
Class Ends/Remediation
Optional: ACS and Stroke Lessons
ADAPTED FROM THE AHA 2011 ACLS MANUAL
Mega Code Test
Group 2
MILITARY TRAINING NETWORK
PROGRAM DIRECTOR NOMINATION FORM
BLS
ACLS
PALS
Instructions: To be completed and sent to the Military Training Network with appropriate signatures. The MTN Director
approves nominations. The Program Director and Program Administrator cannot be the same individual due to the requirement
for separation of duties. Refer to your MTN Handbook for more information. Submit a separate nomination package for
each discipline.
Rank/Name/Title:
Unit Name:
Unit Mailing Address
(No PO Boxes)
Commercial Work Phone:
Duty E-Mail:
Commercial Command Phone:
DSN:
Alternate E-Mail:
DSN:
Fax:
Fax:
Expiration Date of Current Instructor/Training Site Faculty Card:
List the Last Five Courses Taught Within the Last Two Years to Include
Course Type and Date:
Must Include one Instructor Course.
Ex: COURSE NAME DDMMMYY (BLS-R 30 SEP 13)
COURSE NAME DD-DDMMMYY (ACLS-P 12-13 APR 13)
MTN Program Director Commitment: As an MTN Program Director, I agree to uphold the program guidelines set forth by the
Military Training Network and the American Heart Association. I will maintain my instructor and Training Site Faculty
commitments including teaching provider/instructor courses and monitoring instructors. I also agree to strengthen the Chain of
Survival and the mission of the MTN and American Heart Association within my community. Attached is my Training Site
Faculty Card (front and back) and Curriculum Vitae (CV). I assume responsibility for all controlled items associated with this
program.
Date Completed Instructor Essentials Course:
________________________________________________
Signature of Program Director Candidate
Date
Unit Commander/Commanding Officer:
I concur and recommend this appointment.
____________________________________________
Signature of Commander/Commanding Officer
Date
Printed Name of Commander/Commanding Officer
July 17
ALL FORMS MUST BE TYPED – MTN WILL NOT ACCEPT HANDWRITTEN FORMS
MILITARY TRAINING NETWORK
TRAINING SITE FACULTY NOMINATION FORM
BLS
ACLS
PALS
New Nomination
Re-Nomination
Instructions: To be completed and then approved by the Program Director. Training Site Faculty status must be renewed every two
years. Send or fax a copy of this form to the MTN Program Manager; retain a copy in the instructor file along with a copy of the TSF
Card (both front and back) and CV.
Rank/Name/Title:
Unit Name:
Unit Mailing Address:
(No PO Boxes)
Commercial Work Phone:
Duty E-Mail:
Commercial Command Phone:
Command E-Mail:
DSN:
Alternate E-Mail:
DSN:
Fax:
Fax:
How Long has the Candidate been an Instructor?
Expiration Date of Current Instructor/Training Site Faculty Card:
List the Last Five Courses Taught Within the Last Two Years to
Include Course Type and Date:
Must Include one Instructor Course.
Ex: COURSE NAME DDMMMYY (BLS-R 30 SEP 13)
COURSE NAME DD-DDMMMYY (ACLS-P 12-13 APR 13)
MTN Training Site Faculty Commitment: As an MTN Training Site Faculty, I agree to conduct and follow the
regulations set forth by the Military Training Network and the American Heart Association. I agree to maintain my
instructor commitments in addition to fulfilling the responsibilities of a Training Site Faculty. I also agree to strengthen
the Chain of Survival and the mission of the MTN and the American Heart Association within my community.
_____________________________________________
Signature of Training Site Faculty Candidate
Date
Verification of Training Site Faculty Potential: (All Required)
Has been identified as having Training Site Faculty potential during performance as an Instructor.
Has demonstrated Training Site Faculty potential during a screening evaluation.
Has demonstrated exemplary performance of Provider skills.
Has had at least two-year’s experience as an Instructor or has taught at least four to eight courses.
Has served as a lead instructor or course director in at least one MTN course in respective discipline.
For Re-Nomination only: has taught at least one instructor and four provider courses over the past two years.
Completed Instructor Essentials Course:
_______________________
_____________________________
Name/Title
Signature of Program Director
Date
**Nomination and Re-nominations for Program Directors will be signed by the MTN Director**
July 17
ALL FORMS MUST BE TYPED – MTN WILL NOT ACCEPT HANDWRITTEN FORMS
MILITARY TRAINING NETWORK
CURRICULUM VITAE (CV) FORM
PURPOSE: To provide information about Military Training Network (MTN) Program Director (PD) and Training
Site Faculty (TSF).
ROUTINE USES: Documentation of teaching credentials for PD and TSF at training sites and MTN.
Last Name, First Name, MI, Professional Licensure, Branch of Service
Rank
Complete Duty Mailing Address
Duty Station or Employer
Telephone(s)
Comm:
DSN:
Present Position, Duty and Responsibilities
Education Institution
Major
Degree
Year
Other
TEACHING EXPERIENCE AS PROGRAM DIRECTOR, TSF, LEAD INSTRUCTOR OR INSTRUCTOR
FOR BLS, ACLS, AND/OR PALS (TYPE OF CLASS and DATES)
List the last five courses taught in this format (DATE/TYPE/LOCATION):
ANY ADDITIONAL RELEVANT TEACHING EXPERIENCE:
July 17
ALL FORMS MUST BE TYPED – MTN WILL NOT ACCEPT HANDWRITTEN FORMS
MILITARY TRAINING NETWORK
PROGRAM ADMINISTRATOR APPOINTMENT FORM
BLS
ACLS
PALS
Instructions: To be completed then approved by the Program Director. Send a copy of the approved form to the MTN. The
Program Director and Program Administrator cannot be the same individual due to the requirement for separation of duties. Refer to your
MTN Handbook for more information. Submit a separate appointment form for each discipline.
Rank/Name/Title:
Unit Name:
Unit Mailing Address:
(No PO Boxes)
Commercial Work Phone:
Duty E-Mail:
Commercial Command Phone:
DSN:
Alternate E-Mail:
DSN:
Fax:
Fax:
MTN Program Administrator Commitment: As an MTN Program Administrator, I agree to conduct and follow the
regulations set forth by the Military Training Network and the American Heart Association. I will read the Military
Training Network’s Administrative Handbook and use it as the primary guide for my Program.
Program Administrator Orientation Conducted on
________________________________________________
Signature of Program Administrator Candidate
Date
Program Director:
I concur and approve this appointment. I verify that an orientation has been conducted per the MTN
Administrative Handbook.
___________________________________________
Signature of Program Director
Date
Printed Name of Program Director
July 17
ALL FORMS MUST BE TYPED – MTN WILL NOT ACCEPT HANDWRITTEN FORMS