PERFORMANCE CHECKLIST

CPR

NOT
PROCEDURE DONE SCORE
DONE
1. Coming through, coming through, Stand back 2
please The scene is safe.
2. Check responsiveness, Hey hey are you okay? 2X 2
3. Scans the chest for movements (5-10 secs) 2
4. ACTIVATE EMERGENCY RESPONSE SYSTEM, 3
GRAB THE AED.
5. Check for CIRCULATION. (1001-1010). Locate for 3
carotid pulse using point and middle finger.
6. Bares patients chest and locates CPR hand 3
position.
7. Deliver 1st cycle of compression at correct rate 3
(acceptable 18 seconds or less for 30
compressions).
8. Gives 2 breaths (1 second each) 2
AED Arrives 3
9. Turns AED on, selects proper pads, and places pads 2
correctly.
10. Clears patient to analyze (must be visible and verbal 2
check).
11. Clears patient to shock/ presses shock button (must 2
be visible and verbal check; maximum time from
AED arrival less than 45 seconds)
Student Continues CPR 3
12. Delivers second cycle of compressions at correct 3
hand position. (acceptable: greater than 23 of 30
compressions)
13. Gives 2 breaths (1 second each) with visible chest 3
rise.
14. Delivers third cycle of compressions of adequate 2
depth with complete chest recoil

Name: ____________________ Score: _______________

Section: ___________________ Date: _______________
Instructor:__________________
 PERFORMANCE CHECKLIST

CPR

NOT
PROCEDURE DONE SCORE
DONE
1. Survey the scene. The scene is safe. 2
2. I am ________, a trained first aider (show I.D.) I 2
have my BSIP on. Can I help?
3. Check the responsiveness of the victim. Hey, hey 2
hey are you ok? (2x) Victim is unresponsive
4. Man/ Lady in blue.. Please ACTIVATE MEDICAL 3
ASSISTANCE. Call 117 as I further assess the
victim.
5. Check Airway. No obstruction seen. LLF for 5 3
seconds (1001-1005). VICTIM IS BREATHLESS or
(-) Breathing.
6. I give 2 initial blows or puff (or Initial Ventilations).. 3
Blow..Look Listen Feel (LLF)..Blow..Look Listen Feel
(LLF)..
7. Check for CIRCULATION. (1001-1010).. Locate for 3
carotid pulse using point and middle finger.
8. Victim is (-) PULSE & (-) BREATHING. 2
9. Man/ Lady in blue.. Please RE-ACTIVATE MEDICAL 3
ASSISTANCE. Call 117 as I do CPR (30:2 x 5)
10. Re-check circulation for 10 secs. (1001-1010). 2
11. Victim is (+) PULSE & (+) BREATHING. Victim is 2
REVIVED.
12. Put the victim in a recovery position (side lying 2
position).
13. Rub the back (to promote circulation & good 3
opportunity for assessment).
14. Victim is (+) pulse & (+) breathing. Victim is 3
REVIVED.
15. Put the victim in a recovery position. 3
16. Rub the back (to promote circulation & good 2
opportunity for assessment).
17. Monitor Vital Signs. 3
18. Care for shock 3
19. Assist the victims transfer to the nearest hospital. 3

Name: ____________________ Score: _______________

Section: ___________________ Date: _______________
Instructor:__________________