NLS Instructor Nomination Form

Section 1: Candidate details

As the nominating Course Director, we ask that you answer each question. We would like to know about the candidate's most recent attendance on a NZ Resuscitation Council NLS course, their professional qualification in healthcare, and their practical involvement with clinical resuscitation over the past three years.

This form must be submitted within four weeks of the candidate's provider course.

Question Title

* 1. I am:

Name (Course Director):

Provider Centre:

My email address is:

Question Title

* 2. I nominate:

Candidate name:

Candidate email:

Candidate mobile:

Question Title

* 3. The candidate successfully completed their NLS provider course on:
(This date will be validated against course participant sheets)

Date:

Date

Question Title

* 4. The candidate has the following health professional qualification:

Nurse

Doctor

Medical Specialist

Paramedic

Midwife

Other (please specify)

Question Title

* 1. I am:

Question Title

* 2. I nominate:

Question Title

* 3. The candidate successfully completed their NLS provider course on:(This date will be validated against course participant sheets)

Question Title

* 4. The candidate has the following health professional qualification:

Question Title

* 5. The candidate is currently employed as:

* 3. The candidate successfully completed their NLS provider course on:
(This date will be validated against course participant sheets)