CPR for the Healthcare Professional: Basic Life Support (BLS) Choking Practical Skill Evaluation Form – Emergency Medical Services University, LLC

Student Name *

Date *

Passed (Y/N) Y for Yes and N for No *

*Place a check ( ✓ ) mark in deficient areas ONLY.

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

properly victim the

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

A score of 75% 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.**

Instructor Name: *

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