Form VA Form 10-0468 VA Form 10-0468 CPR Class Registration

Minneapolis VA Medical Center
A Member of the VA Midwest Health Care Network (VISN23)

OMB 2900-XXXX
Estimated Burden: 5 min.

education
CPR Class Registration
YOU HAVE CHOSEN CPR [ACLS] [PALS] INSTRUCTOR
Class will be held on __________ at 8:00 AM and ___________ at 6:00 AM at
the location listed below.
ROOM 227-D, Bldg. 68
VA MEDICAL CENTER
ONE VETERANS DRIVE
MINNEAPOLIS, MN 55417
Enter the following information:
* required
status:

VA Employee

* first name:
* last name:
position:

Dr

ward/department:

* phone

/

-

cell phone:

/

-

pager:

/

-

* email:
confirm email:

Please verify the information you typed above is correct. Then click on the register
button below.
If you have any questions about the class, send an email to David.Adriansen@va.gov
Paperwork Reduction Act of 1995 (PRA). In accordance with section 3507 of the PRA, VA may not conduct or
sponsor, and you are not required to respond to a collection of information unless it displays a valid OMB number. VA
anticipates that the time expended by all individuals who complete this survey will average 5 minutes. This includes
the time it will take to read instructions, gather the necessary facts and fill out the form. Disclosure of information
involves release of statistical data and other non-identifying data for the improvement of services within the VA
healthcare system and associated administrative purposes. Submission of this form is voluntary and failure to respond
will have no impact on benefits to which you may be entitled.
Privacy Act Statement: The information collected on this form is necessary to meet the identify proofing
requirements of the VA Medical Center Education Service. The information is used to verify the personal identify
of VA Employees, contractors, and affiliates (such as student, WOC employees, and others) prior to issuing a
Cardiopulmonary Resuscitation (CPR), Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support
(PALS) certification. The collected information is protected in accordance with the Privacy Act of 1974, 5 USC Section
552(3), maintained under the System of Records 57VA125, Voluntary Service, and the authority of 38 UCS, Part I,
Chapter 5, Section 527.

VA Form 10-0468
July 2009

Register