CPR for EMTs – Emergency Medical Services University, LLC

⚡

Did the student pass on their first attempt?

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CPR for EMTs

*EXTREMELY IMPORTANT!!

Only check ( ✓ ) mark FAILED areas!

Student ID *

EMT student ID's are usually in this format: 123456FT-01. For refresher or skills only, place "CE" in this field

Note: Validation of a Student ID may take up to 30 seconds to complete. You may continue filling out this form while validation is in progress.

Date *

Passed (Y/N)? *

Safety of the Scene and Individuals

Verbalizes and properly addresses safety of the scene

Adult
Child
Infant

Recognizes when a scene is unsafe

Adult
Child
Infant

Verbalizes and properly addresses safety of self, others and the victim

Adult
Child
Infant

Takes appropriate precautions (gloves, etc…)

Adult
Child
Infant

Level of Responsiveness/Consciousness & Assessment

Checks to see if the victim is conscious

Adult
Child
Infant

Verbalizes the victims level of responsiveness

Adult
Child
Infant

Places/Ensures the victim is in the appropriate position

Adult
Child
Infant

Compressions/Circulation

Checks for a pulse

Adult
Child
Infant

Provides the appropriate number of chest compressions (if applicable)

Adult
Child
Infant

Airway & Breathing

Properly opens the airway

Adult
Child
Infant

Assesses the airway for foreign objects

Adult
Child
Infant

Looks for breathing

Adult
Child
Infant

Listens for breathing

Adult
Child
Infant

Feels for breathing

Adult
Child
Infant

Provides the appropriate number of breaths

Adult
Child
Infant

Safety of the Scene and Individuals

Verbalizes and properly addresses safety of the scene

Adult
Child
Infant

Recognizes when a scene is unsafe

Adult
Child
Infant

Verbalizes and properly addresses safety of self, others and the victim

Adult
Child
Infant

Takes appropriate precautions (gloves, etc…)

Adult
Child
Infant

Level of Responsiveness/Consciousness & Assessment

Checks to see if the victim is conscious

Adult
Child
Infant

Verbalizes the victims level of responsiveness

Adult
Child
Infant

Determines the need for intervention

Adult
Child
Infant

For Responsive Patient

For an Adult/Child: Ensures abdominal thrusts are performed in an effective manner; For an Infant: Provides 5 back blows followed by 5 chest thrusts in an alternating manner until the object is expelled or the person becomes unconscious

Adult
Child
Infant

Note: If this criteria is marked as deficient, the student fails the evaluation.

For the Unresponsive Patient (Simulate/Ask: What would you do if the person becomes unconscious?)

For an Adult: Assists the patient to the ground in a gentle manner and verbalizes the need to perform CPR; For a Child/Infant: Assists the patient to the ground in a gentle manner (if applicable) and verbalizes the need to perform CPR.

Adult
Child
Infant

Note: If this criteria is marked as deficient, the student fails the evaluation.

Continuation

Alerts 9-1-1

Adult
Child
Infant

Verbalizes a continuous need for continuous care/assessment until help arrives

Adult
Child
Infant

Notes

**A score of 80% or higher is required in each age group to successfully pass the evaluation. A student cannot receive
more than three (3) deficiencies in each area (e.g. adult, child or infant evaluated separately) to pass. Student may attempt this skill 3 times maximum before needing to schedule a separate CPR class.

Administrative Section

Note: EMT Student Candidate Name (Not Refresher) will populate automatically below. If the name has not been populated or the name is incorrect, contact customer service to get the correct STUDENT ID NUMBER.

Candidate *

First

Last

Examiner *

need For etc…)

Instructor State *

Exam Location *

Instructor Certification Number *

Attempt 1 Result *

Attempt 2

Attempt 3 Result

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