TRIPLER ARMY MEDICAL CENTER (TAMC)

RESUSCITATION CERTIFICATION QUESTIONNAIRE

Please type or print all responses:

Name (Last, First, Middle Initial):

Residency program:�

BLS Registered?� Mark with an X.� Bring a current, valid card to inprocessing if �Yes.�

1. Yes:� �� 2. No:� �� 3. Card expiration date (mm/dd/yy):

ACLS Registered?� Mark with an X.� Bring a current, valid card to inprocessing if �Yes.�

1. Yes:� �� 2. No:� �� 3. Card expiration date (mm/dd/yy):

PALS Registered Mark with an X.� Bring a current, valid card to inprocessing if �Yes.�

1. Yes:� �� 2. No:� �� 3. Card expiration date (mm/dd/yy):

NRP Registered? Mark with an X.� Bring a current, valid card to inprocessing if �Yes.�

1. Yes:� �� 2. No:� �� 3. Card expiration date (mm/dd/yy):

ATLS Registered?� Mark with an X.� Bring a current, valid card to inprocessing if �Yes.�

1. Yes:� �� 2. No:� �� 3. Card expiration date (mm/dd/yy):

Incoming interns � All personnel involved in providing patient care must have BLS training biennially.� All newly assigned residents must be ACLS registered prior to assuming inpatient responsibilities or before covering inpatient call.

Pediatric Advanced Life Support (PALS) is REQUIRED For Family Medicine and Pediatrics interns.� It is OPTIONAL for all other interns.

Other interns � Indicate if you want to be scheduled for PALS:� 1.� Yes� �2. No� ��

The Neonatal Resuscitation Program (NRP) Course is REQUIRED for Family Medicine, OB/GYN and Pediatrics interns.� It is OPTIONAL for all other interns.

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Other interns � Indicate if you want to be scheduled for NRP:� 1.� Yes� � 2. No� ��

Signature:�� Date:

FAX the completed questionnaire to the Tripler Army Medical Center Graduate Medical Education Office at (808) 433-1559.� Or you may email it to:

yolanda.johnson@amedd.army.mil or gary.christal@us.army.mil