COMMUNITY SAFETY CONSULTANTS AHA CPR COURSE RECORD SHEET

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Beverly Gilbert
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1 Revised CSC COURSE #: COMMUNTY SAFETY CONSULTANTS AHA CPR COURSE RECORD SHEET Organization: Address: ZP: Date: Start Time: End Time: Total Hours: Total Days: # of nitial students: # of Renewal students: : # of NC students: ; Student/Manikin Ratio: 3:1 (Max = 3:1) nstr/student Ratio: (Max: 1:6) Manikin decon following CSC policy by: >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Lead nstr: nstr Phone #: - - Cards to be picked up by instructor Asst nstrs 1) 2) 3) NSTRUCTOR COMMENTS (include remediations): Note: Students need a score of 84% or above on the written test to pass or they MUST be remediated. acknowledge by signing below that above class was taught to AHA guidelines. also either gave or verified the students received a book and have attached proof of either. nstructor Signature: Date: CHECK OFF ONE COURSE MARK OFF SKLLS COMPLETED [ ] H/S CPR Adult Child nfant [ ] H/S First Aid [ ] H/S FA/CPR Adult Child nfant [ ] H/S Pediatric FA/CPR Adult Child nfant [ ] BLS [ ] BLS- Renewal [ ] nstructor BLS Heartsaver [ ] Family & Friends Equipment Used: Lead instructor must fill in for all classes AHA Bag #: AED Trainer(s) #: Manikin #s used in class Adult: Child: nfant: F/A nstructor Box #: F/A Bag #: F/A Box #s: Other Equipment used (type): ^^^^^^^^^^^^^ Office use only ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ Paid $: PO: Check: Amount Date Cards sent on: / / To whom: E Cards sent on: / / To whom:

2 BLS REN PLEASE - NEATLY PRNT NFORMATON FRST NAME LAST NAME ADDRESS (Street, City, State) Write grade less than 84. Fill Passing grade later Practical & Final P- Pass, R- Remediate, - nc. ZP CODE PHONE COURSE DATES WRT. PRAC FN NC PD $ AMT 1 EMAL: 2 EMAL: 3 EMAL: 4 EMAL: 5 EMAL: 6 EMAL: 7 EMAL: 8 EMAL: 9 EMAL: 1 0 EMAL: NSTRUCTORS: Please be sure the above list is LEGBLE and COMPLETE before submitting. CPR06/13/18

Adult CPR and AED Skills Testing Checklist Student Name v American Heart Association.

You check that the scene is safe and then approach the patient. Demonstrate what you would do next." Prehospital Scenario: "You arrive on the scene for a suspected cardiac arrest.

" Assessment and Activation 0 Checks responsiveness 0 Shouts for help/activates emergency response system/sends for AED 0 Checks breathing 0 Checks pulse Cycle 1 of CPR {30:2) *CPR feedback devices

3 Adult CPR and AED Skills Testing Checklist Student Name v American Heart Association.. life is why' Date of Test Hospital Scenario: "You are working in a hospital or clinic, and you see a person who has suddenly collapsed in the hallway. You check that the scene is safe and then approach the patient. Demonstrate what you would do next." Prehospital Scenario: "You arrive on the scene for a suspected cardiac arrest. No bystander CPR has been provided. You approach the scene and ensure that it is safe. Demonstrate what you would do next." Assessment and Activation 0 Checks responsiveness 0 Shouts for help/activates emergency response system/sends for AED 0 Checks breathing 0 Checks pulse Cycle 1 of CPR {30:2) *CPR feedback devices preferred for accuracy Once student shouts for help, instructor says, "Here's the barrier device. am going to get the AED." Adult Compressions 0 Performs high-quality compressions*: Hand placement on lower half of sternum 30 compressions in no less than 15 and no more than 18 seconds Compresses at least 2 inches (5 em) Complete recoil after each compression ~ Adult Breaths 0 Gives 2 breaths with a barrier device: Each breath given over 1 second Visible chest rise with each breath Resumes compressions in less than 10 seconds Cycle 2 of CPR {repeats steps in Cycle 1) Only check box if step is successfully performed 0 Compressions 0 Breaths 0 Resumes compressions in less than 10 seconds \ Rescuer 2 says, "Here is the AED. 'll take over compressions, and you use the AED." \.. AED {follows prompts of AED) 0 Powers on AED 0 Correctly attaches pads 0 Clears for analysis 0 Clears to safely deliver a shock 0 Safely delivers a shock Resumes Compressions 0 Ensures compressions are resumed immediately after shock delivery Student directs instructor to resume compressions or Student resumes compressions ~ """' nstructor Notes STOP TEST Place a./ in the box next to each step the student completes successfully. f the student does not complete all steps successfully (as indicated by at least 1 blank check box), the student must receive remediation. Make a note here of which skills require remediation (refer to nstructor Manual for information about remediation). Test Results Check PASS or NR to indicate pass or needs remediation: PAss [ :1 NRD nstructor nitials nstructor Number Date 2016 American Heart Association

Adult CPR and AED Skills Testing Critical Skills Descriptors 1. Assesses victim and activates emergency response system (this must precede starting compressions) within a maximum of 30 seconds.

normal breathing (only gasping) - Scans from the head to the chest for a minimum of 5 seconds and no more than 1 0 seconds Checks carotid pulse - Can be done simultaneously with check for breathing -

4 Adult CPR and AED Skills Testing Critical Skills Descriptors 1. Assesses victim and activates emergency response system (this must precede starting compressions) within a maximum of 30 seconds. After determining that the scene is safe: Checks for responsiveness by tapping and shouting Shouts for help/directs someone to call for help and get AED/defibrillator Checks for no breathing or no normal breathing (only gasping) - Scans from the head to the chest for a minimum of 5 seconds and no more than 1 0 seconds Checks carotid pulse - Can be done simultaneously with check for breathing - Checks for a minimum of 5 seconds and no more than 1 0 seconds 2. Performs high-quality chest compressions (initiates compressions immediately after recognition of cardiac arrest) Correct hand placement - Lower half of sternum - 2-handed (second hand on top of the first or grasping the wrist of the first hand) Compression rate of 1 00 to 120/min - Delivers 30 compressions in 15 to 18 seconds Compression depth and recoil-at least 2 inches (5 em) and avoid compressing more than 2.4 inches (6 em) - Use of a commercial feedback device or high-fidelity manikin is highly recommended - Complete chest recoil after each compression Minimizes interruptions in compressions - Delivers 2 breaths so less than 10 seconds elapses between last compression of one cycle and first compression of next cycle - Compressions resumed immediately after shock/no shock indicated 3. Provides 2 breaths by using a barrier device Opens airway adequately - Uses a head tilt-chin lift maneuver or jaw thrust Delivers each breath over 1 second Delivers breaths that produce visible chest rise Avoids excessive ventilation Resumes chest compressions in less than 1 0 seconds 4. Performs same steps for compressions and breaths for Cycle 2 5. AED use Powers on AED - Turns AED on by pushing button or lifting lid as soon as it arrives Correctly attaches pads - Places proper-sized (adult) pads for victim's age in correct location Clears for analysis - Clears rescuers from victim for AED to analyze rhythm (pushes analyze button if required by device) - Communicates clearly to all other rescuers to stop touching victim Clears to safely deliver shock - Communicates clearly to all other rescuers to stop touching victim Delivers a shock - Resumes chest compressions immediately after shock delivery - Does not turn off AED during CPR 6. Resumes compressions Ensures that high-quality chest compressions are resumed immediately after shock delivery - Performs same steps for compressions

nfant CPR Skills Testing Checklist (1 of 2) Student Name _ American Heart Association life is why Date of Test Hospital Scenario: "You are working in a hospital or clinic when a woman runs through

You send your coworker to activate the emergency response system and to get the emergency equipment." Prehospital Scenario: "You arrive on the scene for an infant who is not breathing.

" Assessment and Activation 0 Checks responsiveness 0 Shouts for help/activates emergency response system 0 Checks breathing 0 Checks pulse Cycle 1 of CPR (30:2) *CPR feedback devices preferred for

5 nfant CPR Skills Testing Checklist (1 of 2) Student Name _ American Heart Association life is why Date of Test Hospital Scenario: "You are working in a hospital or clinic when a woman runs through the door, carrying an infant. She shouts, 'Help me! My baby's not breathing.' You have gloves and a pocket mask. You send your coworker to activate the emergency response system and to get the emergency equipment." Prehospital Scenario: "You arrive on the scene for an infant who is not breathing. No bystander CPR has been provided. You approach the scene and ensure that it is safe. Demonstrate what you would do next." Assessment and Activation 0 Checks responsiveness 0 Shouts for help/activates emergency response system 0 Checks breathing 0 Checks pulse Cycle 1 of CPR (30:2) *CPR feedback devices preferred for accuracy Once student shouts for help, instructor says, "Here's the barrier device." nfant Compressions 0 Performs high-quality compressions*: Placement of 2 fingers in the center of the chest, just below the nipple line 30 compressions in no less than 15 and no more than 18 seconds Compresses at least one third the depth of the chest, about 1 Yz inches (4 em) Complete recoil after each compression nfant Breaths 0 Gives 2 breaths with a barrier device: Each breath given over 1 second Visible chest rise with each breath Resumes compressions in less than 10 seconds Cycle 2 of CPR (repeats steps in Cycle 1) Only check box if step is successfully performed 0 Compressions 0 Breaths 0 Resumes compressions in less than 10 seconds Rescuer 2 arrives with bag-mask device and begins ventilation while Rescuer 1 continues compressions with 2 thumb-encircling hands technique. Cycle 3 of CPR Rescuer 1: nfant Compressions 0 Performs high-quality compressions*: 15 compressions with 2 thumb-encitcling hands technique 15 compressions in no less than 7 and no more than 9 seconds Compresses at least one third the depth of the chest, about 1 Y2 inches (4 em) Complete recoil after each compression """" Rescuer 2: nfant Breaths This rescuer is not evaluated. (continued) 2016 American Heart Association

nfant CPR Skills Testing Checklist (2 of 2) Student Name ~-------------------------- American Heart Association life is why Date of Test 1 Cycle 4 of CPR Rescuer 2: nfant Compressions This rescuer is

Rescuer 1: nfant Breaths D Gives 2 breaths with a bag-mask device: Each breath given over 1 second Visible chest rise with each breath Resumes compressions in less than 10 seconds ' STOP TEST

6 nfant CPR Skills Testing Checklist (2 of 2) Student Name ~ American Heart Association life is why Date of Test 1 Cycle 4 of CPR Rescuer 2: nfant Compressions This rescuer is not evaluated. Rescuer 1: nfant Breaths D Gives 2 breaths with a bag-mask device: Each breath given over 1 second Visible chest rise with each breath Resumes compressions in less than 10 seconds ' STOP TEST nstructor Notes Place a./ in the box next to each step the student completes successfully. f the student does not complete all steps successfully (as indicated by at least 1 blank check box), the student must receive remediation. Make a note here of which skills require remediation (refer to nstructor Manual for information about remediation). Test Results Check PASS or NR to indicate pass or needs remediation: PASS D NR D nstructor nitials nstructor Number Date "'\ 2016 American Heart Association

nfant CPR Skills Testing Critical Skills Descriptors 1. Assesses victim and activates emergency response system (this must precede starting compressions) within a maximum of 30 seconds.

normal breathing (only gasping) - Scans from the head to the chest for a minimum of 5 seconds and no more than 1 0 seconds Checks brachial pulse - Can be done simultaneously with check for breathing

7 nfant CPR Skills Testing Critical Skills Descriptors 1. Assesses victim and activates emergency response system (this must precede starting compressions) within a maximum of 30 seconds. After determining that the scene is safe: Checks for responsiveness by tapping and shouting Shouts for help/directs someone to call for help and get emergency equipment Checks for no breathing or no normal breathing (only gasping) - Scans from the head to the chest for a minimum of 5 seconds and no more than 1 0 seconds Checks brachial pulse - Can be done simultaneously with check for breathing - Checks for a minimum of 5 seconds and no more than 1 0 seconds 2. Performs high-quality chest compressions during 1-rescuer CPR (initiates compressions within 10 seconds of identifying cardiac arrest) Correct placement of hands/fingers in center of chest - 1 rescuer: 2 fingers just below the nipple line Compression rate of 1 00 to 120/min - Delivers 30 compressions in 15 to 18 seconds Adequate depth for age - nfant: at least one third the depth of the chest (about 1112 inches [4 em]) - Use of a commercial feedback device or high-fidelity manikin is highly recommended Complete chest recoil after each compression Appropriate ratio for age and number of rescuers - 1 rescuer: 30 compressions to 2 breaths Minimizes interruptions in compressions - Delivers 2 breaths so less than 1 0 seconds elapses between last compression of one cycle and first compression of next cycle 3. Provides effective breaths with bag-mask device during 2-rescuer CPR Opens airway adequately Delivers each breath over 1 second Delivers breaths that produce visible chest rise Avoids excessive ventilation Resumes chest compressions in less than 1 0 seconds 4. Switches compression technique at appropriate interval as prompted by the instructor (for purposes of this evaluation). Switch should take no more than 5 seconds. 5. Performs high-quality chest compressions during 2-rescuer CPR Correct placement of hands/fingers in center of chest - 2 rescuers: 2 thumb-encircling hands just below the nipple line Compression rate of 1 00 to 120/min - Delivers 15 compressions in 7 to 9 seconds Adequate depth for age - nfant: at least one third the depth of the chest (about 1% inches [4 em]) Complete chest recoil after each compression Appropriate ratio for age and number of rescuers - 2 rescuers: 15 compressions to 2 breaths Minimizes interruptions in compressions - Delivers 2 breaths so less than 10 seconds elapses between last compression of one cycle and first compression of next cycle

8 ANSWER SHEET BLS fow H!eahhcare Providers Wrrittelllt Exam Name: Date:! Test Versnon: fes~ SG.:olre: Test Boolkle1l: Noo: ust at"tai11 ~ "ore of 8Jl%, nr hetter to pas> thrrs Q\\liestnoiill 0 (B) Al!1SW\Cir (~) ) G 4 (C\ ') 0 G) f2l (, Q (~ Q 8 G G) G ';) 10 ll 13 ~) 14 l s ]() 0 fc1 j7 G (~) \ S' '? 18 0 Q) 19 (!) 20 G C0 (D) -.:::/ _J ) ' (~) ~~ 2/f

9 ECC Course Evaluation BLS Classroom Course Date nstructor(s) Training Center Location Please answer the following questions about your nstructor. My nstructor: 1. Provided instruction and help during my skills practice session 2. Answered all of my questions before my skills test 3. Was professional and courteous to the students Please answer the following questions about the course content. 1. The course learning objectives were clear. 2. The overall level of difficulty of the course was a. Too hard b. Too easy c. Appropriate 3. The content was presented clearly. 4. The quality of videos and written materials was a. Excellent b. Good c. Fair d. Poor 5. The equipment was clean and in good working condition. Please answer the following questions about your skill mastery. 1. The course prepared me to successfully pass the skills session. 2. am confident can use the skills the course taught me. c. Not sure 3. will respond in an emergency because of the skills learned in this course. c. Not sure 4. took this course to obtain professional education credit or continuing education credit. Optional questions: Have you previously taken this course via another method, such as in a classroom or online? Which learning method do you prefer and why? Were there any strengths or weaknesses of the course that you would like to comment on? What would you like to see in future courses developed by the AHA? After Completing This Evaluation Please return this evaluation to your nstructor before you leave the class. Alternatively, you can send the evaluation to your nstructor s Training Center. Ask your nstructor for the contact information. f you have significant problems or concerns with your course, please contact the AHA at 877-AHA-4CPR. KJ0920 BLS CLASS R2/ American Heart Association

Once student shouts for help, instructor says, Here s the barrier device. I am going to get the AED. STOP TEST

Once student shouts for help, instructor says, Here s the barrier device. I am going to get the AED. STOP TEST Adult CPR and AED Adult Skills CPR Testing and Checklist AED Skills Testing Checklist Hospital Scenario: You are working in a hospital or clinic, and you see a person who has suddenly collapsed in the