Skill Sheet 1: Using an AED* and Adult CPR
Student Name
Instructor Name
Test Date
Instructor Number
Review the Skill Sheet with students and explain the required steps. During the skill check give assessment information, but not correct actions to take.
Check off each step as it is performed successfully. If the student fails any portion of the skill check, practice, provide feedback, and retest the entire
skill. Use as many skill sheets as required until proficient.
Instructor Options: 1) Test each student’s skills individually on CPR and AED use. 2) Pair up students and test one student on CPR and the other on
AED use at the same time. CPR provider should perform at least 2 cycles of CPR before the AED arrives. Switch roles and test again.
Skill Check 1A: Using an AED*
#
Required Action
1.
Power on AED: Place AED near victim’s head, power on AED.
2.
Apply Pads to Bare Skin: Right upper chest below collarbone; left lower chest.
3.
Clear Victim: State, “Clear!” or “Everybody clear!”
Look up and down to ensure no one is touching the victim or clothes.
4.
Press Shock Button When Victim is Clear
5.
Resume CPR: Start with compressions (or take over compressions if 2 rescuers).
Shock the victim and resume compression within 90 seconds of AED arrival.

Comments
Time: ___ seconds
Skill Check 1B: Adult CPR
#
Required Action

Comments
1.
Scene Size-Up: Look around, state, “Checking for safety.”
State, “I am putting on gloves.”
2.
Establish Response: Tap on shoulder, shout. (The victim is unresponsive)
3.
Activate EMS: Yell for help. Send a bystander to call 9-1-1 and get an AED.
4.
Check Breathing: Scan the chest for 5-10 seconds. (There is no chest movement)
5.
30 Compressions: 2 hands in the center of the chest between the nipples.
30 compressions in 18 seconds or less.
Time: ___ seconds
6.
2 Breaths: Open airway using head tilt/chin lift.
Use a barrier device and give 2 breaths, with visible chest rise for at least 1 breath.
10 seconds or less to give 2 breaths and resume compressions.
Time: ___ seconds
7.
30 Compressions: At least 2 inches deep and with full recoil.
__________________________________________________________________________________________________
Instructor Signature
Date
*Skill Check 1A: ‘Using an AED’ is required for AED certification.
©EMS Safety 2011
CPR & AED for Community Rescuers
Version A
Skill Sheet 2: Child and Infant CPR*
Student Name
Instructor Name
Test Date
Instructor Number
Review the Skill Sheet with students and explain the required steps. During the skill check give assessment information, but not correct actions to take.
Check off each step as it is performed successfully. If the student fails any portion of the skill check, practice, provide feedback, and retest the entire skill.
Use as many skill sheets as required until proficient.
Skill Check 2A: Child CPR*
#
Required Action

Comments
1.
Scene Size-Up: Look around, state, “Checking for safety.”
State, “I am putting on gloves.”
2.
Establish Response: Tap on shoulder, shout. (The victim is unresponsive)
3.
Activate EMS: Yell for help. Send a bystander to call 9-1-1 and get an AED.
4.
Check Breathing: Scan chest for 5-10 seconds. (There is no chest movement)
5.
30 Compressions: 1 or 2 hands in the center of the chest between the nipples.
30 compressions in 18 seconds or less.
Time: ___ seconds
6.
2 Breaths: Open airway using head tilt/chin lift.
Use a barrier device and give 2 breaths, with visible chest rise for at least 1 breath.
10 seconds or less to give 2 breaths and resume compressions.
Time: ___ seconds
7.
30 Compressions: About 2 inches deep and with full recoil.
Skill Check 2B: Infant CPR*
#
Required Action

Comments
1.
Scene Size-Up: Look around, state, “Checking for safety.”
State, “I am putting on gloves.”
2.
Establish Response: Flick soles of feet, shout. (The victim is unresponsive)
3.
Activate EMS: Yell for help. Send a bystander to call 9-1-1 and get an AED.
4.
Check Breathing: Scan chest for 5-10 seconds. (There is no chest movement)
5.
30 Compressions: 2 fingers in the center of the chest just below the nipple line.
30 compressions in 18 seconds or less.
Time: ___ seconds
6.
2 Breaths: Open airway using head tilt/chin lift.
Use a barrier device and give 2 breaths over mouth and nose, with visible chest rise
for at least 1 breath. 10 seconds or less to give 2 breaths and resume compressions.
Time: ___ seconds
7.
30 Compressions: About 1½ inches deep and with full recoil.
__________________________________________________________________________________________________
Instructor Signature
Date
*Skill Check 2A and 2B: ‘Child CPR’ and ‘Infant CPR’ are both required for pediatric certification.
©EMS Safety 2012
CPR and AED for Community Rescuers
Version B
Skill Sheet 3: Glove Removal, Choking Care*
Student Name
Instructor Name
Test Date
Instructor Number
Review the Skill Sheet with students and explain the required steps. During the skill check give assessment information, but not correct actions to take.
Check off each step as it is performed successfully. If the student fails any portion of the skill check, practice, provide feedback, and retest the entire
skill. Use as many skill sheets as required until proficient.
Skill Check 3A: Glove Removal
#
Required Action
1.
Pinch: Pinch base of glove, gently peel off, and hold in gloved hand.
2.
Peel: Slip ungloved finger(s) under base of glove, slowly peel glove back.
3.
Pull: Gloves are inside out, one glove stored inside the other.

Skill Check 3B: Adult/Child Choking Care
Required Action

#
1.
Recognize Choking: (Show universal sign) Ask, “Are you choking?” (Nod yes)
2.
Positioning: (Use a manikin) Stand behind victim. Place fist, thumb side in, just
above navel. Grasp fist with free hand.
3.
Abdominal Thrusts: Provide (5 or more) quick, forceful, inward and upward
abdominal thrusts.
Comments
Comments
Victim Becomes Unresponsive (lay manikin on ground)
4.
Activate EMS: Send bystander to call 9-1-1.
5.
Unresponsive Choking Adult: (Review only) 30 compressions, look in mouth for
object, attempt 2 breaths, and repeat 30 compressions.
Skill Check 3C: Infant Choking Care*
Required Action

#
1.
Recognize Choking: (Use infant manikin): Verbalize 3 signs of a conscious choking
infant. (The infant is choking)
2.
Activate EMS: Send bystander to call 9-1-1.
3.
Position Infant: Sit or kneel. Hold infant face down on forearm with head slightly
lower than body; support the jaw between the thumb and forefinger.
4.
5 Back Blows: Forceful back slaps w/ the heel of the hand between the shoulder
blades.
5.
Position Infant: Support infant, turn face up, keep head lower than body.
6.
5 Chest Thrusts: Quick downward chest thrusts with 2 fingers in the center of the
chest, just below the nipples.
7.
Unresponsive Choking Infant: (Review only) 30 compressions, look in mouth,
remove object if seen, repeat.
Comments
_______________________________________________________________________________________________
Instructor Signature
Date
*Skill Check 3C: ‘Infant Choking Care’ is required for Infant certification.
©EMS Safety 2011
CPR & AED for Community Rescuers, Basic First Aid
Version A
Skill Sheet 4: FA Assessment, Bleeding
Student Name
Instructor Name
Test Date
Instructor Number
\
Review the Skill Sheet with students and explain the required steps. During the skill check give assessment information, but not correct actions to take.
Check off each step as it is performed successfully. If the student fails any portion of the skill check, practice, provide feedback, and retest the entire skill.
Use as many skill sheets as required until proficient.
Skill Check 4A: FA Assessment

#
Required Action
1.
Scene Size-Up: Look around, state, “Checking for safety.” State, “Putting on gloves.”
2.
Establish Response: Tap on shoulder, shout. (The victim is unresponsive)
3.
Activate EMS: Send bystander to go call 9-1-1.
4.
Assess Breathing: Scan chest for movement for 5-10 seconds. (The victim is
breathing normally) Does not move the victim unnecessarily.
5.
Assess Head-to-Toe: Scan body for injury from head-to-toe. (The victim is bleeding
heavily from left lower arm)
6.
Treat Life-Threatening Injuries First: Use available materials to control bleeding.
Skill Check 4B: Bleeding and Bandaging
Required Action

#
1.
Apply Firm, Direct Pressure: Wear gloves. Apply firm direct pressure with a gauze
pad directly over the wound.
2.
Add Dressings: (The dressing becomes soaked with blood) Add additional
dressings and quickly reapply direct pressure.
3.
Secure Dressing: Wrap wound with roller gauze or elastic wrap. Start furthest from
the heart and work upward. The bandage is snug but not too tight.
4.
Recheck wound: Check circulation past bandage. Check for blood soaking through.
Skill Check 4C: Use of an Epinephrine Auto-Injector
Required Action

#
1.
Remove Safety Cap
2.
Press Tip Firmly Against Thigh
3.
Hold in Place for 10 Seconds
4.
Remove Auto-Injector and Rub Injection Site for 10 Seconds
Comments
Comments
Comments
_________________________________________________________________________________________________
Instructor Signature
Date
©EMS Safety 2011
Basic First Aid
Version A