BLS Certification

If you are working at a legacy Ascension Location: DO NOT COMPLETE

If you are working at a legacy HFH Location:

Please complete the sections below pertaining to your Basic Life Support (BLS) certification if you have been hired as a Registered Nurse, Medical Assistant, Nurse Assistant, Nurse Extern, Nurse Resident, Patient Safety Assistant, or LPN. All other titles disregard.

You will also need to bring your BLS card to clinical orientation. Nursing leadership will review your form and BLS card to determine if you need to attend BLS classes at Henry Ford Health.

*Asterisk indicates required field.

General Information

First Name Last Name Email Start Date Job Title (if other, no need to submit form) Location

BLS Certification Status

Is your BLS certification issued by the American Heart Association? Yes No I cannot find my BLS card If you answered "Yes" above, please complete the following details. If answered no or cannot find your BLS card, please just sign below and submit form. BLS Heartsaver BLS CPR AED BLS Health Care Provider BLS First Aid CPR AED Issue Date Expiration Date Note: You will need to bring your BLS card to your clinical orientation.

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Applicant Signature Date

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BLS Certification

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BLS Certification Status

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