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

Skills Section

Action

Points Possible

Points Awarded

Takes or verbalizes appropriate PPE precautions

1

Checks responsiveness

1

Requests additional EMS assistance

1

Checks breathing and pulse simultaneously

1

Opens airway properly

1

Prepares rigid suction catheter

1

Turns on power to suction device or retrieves manual suction device

1

Inserts rigid suction catheter without applying suction

1

Suctions the mouth and oropharynx

1

Opens the airway manually

1

Inserts oropharyngeal airway

1

**Ventilates the patient immediately using a BVM device unattached to oxygen
[**Award this point if candidate elects to ventilate initially with BVM attached to reservoir and oxygen so long as 1
first ventilation is delivered within 30 seconds.]

1

Re-checks pulse for no more than 10 seconds

1

Attaches the BVM assembly [mask, bag, reservoir] to oxygen [15 L/minute]

1

Ventilates the patient adequately
-Proper volume to cause visible chest rise (1 point)
-Proper rate [10 – 12/minute (1 ventilation every 5 – 6 seconds)] (1 point)

2

Military Time Only (example: 1523)

Critical Criteria Section

Critical Criteria

Administrative Section

Clear Signature