BLS COURSE  ADEQUATE RATE: at 2.

attached and operates

Out of Hospital 1 and 2 Rescuer Adult CPR and AED Skills Sheet 100-120/min (delivers AED.
each set of 30 chest  Power on
Name Score compressions in 15-18  Selects proper
secs.) AED pads and
Skill
Critical Performance Criteria Attach/places
Step
pads correctly.
1 RESCUER SKILLS EVALUATION: Evaluate the student’s ability to initiate BLS and
deliver high-quality CPR for 5 cycles. Removes clothing
using scissors to
ASSESSES: (at least 5 secs. but no more than 10 sec) secs.
 Checks for scene safety expose victim’s
 Introduces self chest. (prior to
1  Checks responsiveness (if not yet done by 1st attaching pads)
responder)  Clears victim to
 Activate Medical Assistance/Call for Help Analyze
(Rescuer’s hands
2 Cover victims’ mouth and nose with face mask off the victim)
Clears victim to
Simultaneously look for no breathing or only gasping and secs.
shock/presses Shock
3 checks for PULSE no more than 10 secs. (DO NOT LISTEN
AND DO NOT FEEL FOR BREATHING) button (Verbally commands
1st Rescuer: GIVES HIGH Second to clear rescuer’s hands off
QUALITY CPR: Rescuer:(Simultaneously 5 Cycles or 2 the victim)
4
performs procedure with minute cycle
1st rescuer  ADEQUATE DEPTH: 3. MINIMIZES
Delivers compressions at INTERRUPTIONS and
 Correct Positioning: 1. Places BVM at Head Rescuer 1 Rescuer 2
least 2 inches - 2.4 inches successfully delivers 2
 Kneel facing the Part of victim in depth (at least 23 out of ventilations using Bag-
victim’s chest 30) (5 - 6 cm). Valve-Mask (BVM)
 Correct hand placement  ALLOWS COMPLETE (Ensure HEPA Filter is
(Center of the victim’s CHEST RECOIL (at least attached) (2 cycles –
chest/2 hands on the
23 out of 30) while over 1 sec per cycle)
lower half of the
maintaining the heel of  Head Tilt-Chin Lift to
sternum).
one hand in contact support the chin.
 Place the heel of the
with victim’s chest  Executes C and E
second hand on top
of the first so that the Technique ensuring
hands are overlapped BVM seals victims
and parallel. mouth completely.
 Elbows locked and  Gives adequate
perpendicular to the Ventilation to allow
victim’s chest visible chest rise.
(shoulders of rescuer Lifts BVM while Chest
in line with victim’s Compression is ongoing (if
head) BVM is not connected to
Rescuer observes O2 Tank).
victim’s face while
doing CPR.
First Rescuer Bag-Mask Ventilation
Both rescuers resume HIGH QUALITY CPR
5 SECOND RESCUER gives 30 compressions after shock
delivery (2cycles)
Proper Switching of Roles
6 Performs proper switching of roles.
7 Perform proper doffing of PPEs
8 Perform proper decontamination of equipment

Test Results CPR Skills P F

AED Skills P F

Instructor Date Signed

Note: Legend:
32 items if with AED and BVM (Blue and Green Box) P - Passed
17 items without AED and BVM Single Rescuer Only (Blue boxes only) F – Failed