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Candidate:
EMT student ID’s are usually in this format: 123456FT-01. For refresher or skills only, place “CE” in this field
Examiner:
Military Time Only (example: 1523)

Skills Section

Action

Points Possible

Points Awarded

Dons or verbalizes appropriate PPE for skill.

1

Opens the airway manually.

1

Elevates tongue appropriately and inserts OPA or NPA adjunct.

1

Note: Examiner states “No gag reflex is present and the patient accepts the airway.”

Ventilates patient immediately with BVM device, quickly ensures oxygen is attached.

1

EMT directs or demonstrates assessment of effective ventilations via auscultation.

1

Note: Examiner states “Medical direction has ordered insertion of supraglottic airway.”

Selects and prepares supraglottic airway device.

1

Lubricates distal tip of device as appropriate.

1

Positions head appropriately and performs a tongue-jaw lift.

1

Inserts device according to manufacturer’s directions to proper depth.

1

Properly inflates any cuffs (if present), and secures device appropriately.

1

Ventilates patient while assessing for breath sounds over lungs and epigastrium.

1

Note: Examiner states “You auscultate clear breath sounds and no epigastric sounds.”

EMT demonstrates proper rate and depth of ventilations.

1

Military Time Only (example: 1523)

Critical Criteria Section

Critical Criteria

Administrative Section

Clear Signature