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, I suspect the
victim is suffering from cardiac arrest (30:2 x 5)
10. Re-check circulation for 10 secs. (1001-1010). 2
11. Victim is (+) PULSE & (-) BREATHING. 2
12. Man/ Lady in blue.. Please RE-ACTIVATE MEDICAL
ASSISTANCE. Call 117 as I do RB, I suspect the
victim is suffering from respiratory arrest (12:12 or
24 cycles)
13. Re-check circulation for 10 secs. (1001-1010).
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
50

Name: ____________________ Score: _______________

Section: ___________________ Date: _______________
Instructor:__________________
 PERFORMANCE CHECKLIST

Rescue Breathing

NOT
PROCEDURE DONE SCORE
DONE
1. Head tilt, Chin lift, mouth to mouth 3
2. Start with a Blow 3
3. Count 1,1002,1003, 1001, blow 1
4. Count 1,1002,1003, 1002, blow 1
5. Count 1,1002,1003, 1003, blow 1
6. Count 1,1002,1003, 1004, blow 1
7. Count 1,1002,1003, 1005, blow 1
8. Count 1,1002,1003, 1006, blow 1
9. Count 1,1002,1003, 1007, blow 1
10. Count 1,1002,1003, 1008, blow 1
11. Count 1,1002,1003, 1009, blow 1
12. Count 1,1002,1003, 1010, blow 1
13. Count 1,1002,1003, 1011, blow 1
14. Count 1,1002,1003, 1012, blow 1
15. Count 1,1002,1003, 1013, blow 1
16. Count 1,1002,1003, 1014, blow 1
17. Count 1,1002,1003, 1015, blow 1
18. Count 1,1002,1003, 1016, blow 1
19. Count 1,1002,1003, 1017, blow 1
20. Count 1,1002,1003, 1018, blow 1
21. Count 1,1002,1003, 1019, blow 1
22. Count 1,1002,1003, 1020, blow 1
23. Count 1,1002,1003, 1021, blow 1
24. Count 1,1002,1003, 1022, blow 1
25. Count 1,1002,1003, 1023, blow 1
26. Count 1,1002,1003, 1024 1
27. End with blow 1
28. Victim is (+) pulse & (+) breathing. Victim is 3
REVIVED.
29. Put the victim in a recovery position. 3
30. Rub the back (to promote circulation & good 3
opportunity for assessment).
31. Monitor Vital Signs. 3
32. Care for shock 3
33. Assist the victims transfer to the nearest hospital. 3
50

Name: ____________________ Score: _______________

Section: ___________________ Date: _______________
Instructor:__________________