NREMT Skills – OXYGEN ADMINISTRATION BY NON-REBREATHER MASK – Emergency Medical Services University, LLC

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Student ID:

EMT student ID’s are usually in this format: 123456FT-01. For refresher or skills only, place “CE” in this field.

Note: Validation of a Student ID may take up to 30 seconds to complete. You may continue filling out this form while validation is in progress.

Date:

Actual Time Started:

Military Time Only (example: 1523)

Skills Section

Action

Points Possible

Points Awarded

Takes or verbalizes appropriate PPE precautions

Point 1

Gathers appropriate equipment

Point 2

Cracks valve on the oxygen tank

Point 3

Assembles the regulator to the oxygen tank

Point 4

Opens the oxygen tank valve

Point 5

Checks oxygen tank pressure

Point 6

Checks for leaks

Point 7

Attaches non-rebreather mask to correct port of regulator

Point 8

Turns on oxygen flow to prefill reservoir bag

Point 9

Adjusts regulator to assure oxygen flow rate of at least 10 L/minute

Point 10

Attaches mask to patient’s face and adjusts to fit snugly

Point 11

Total Points (Out of 11)

Actual Time Ended:

Military Time Only (example: 1523)

Critical Criteria Section

Critical Criteria

Failure to take or verbalize appropriate PPE precautions
Failure to assemble the oxygen tank and regulator without leaks
Failure to prefill the reservoir bag
Failure to adjust the oxygen flow rate to the non-rebreather mask of at lease 10 L/minute
Failure to ensure a tight mask seal to patient’s face
Failure to manage the patient as a competent EMT
Exhibits unacceptable affect with patient or other personnel
Uses or orders a dangerous or inappropriate intervention

Notes

Administrative Section

Note: EMT Student Candidate Name (Not Refresher) will populate automatically below. If the name has not been populated or the name is incorrect, contact customer service to get the correct STUDENT ID NUMBER.

Candidate:

First

Last

Examiner:

First

Last

Instructor State

Exam Location:

Instructor Certification Number:

Attempt 1 Result

Attempt 2 Result

Attempt 3 Result

Instructor Signature

Clear Signature

Notes Point Instructor

By clicking the submit button below, I hereby agree to make an electronic copy of the form contained here.

EMS University

Did the student pass on their first attempt?

Note: Validation of a Student ID may take up to 30 seconds to complete. You may continue filling out this form while validation is in progress.

Skills Section

Critical Criteria Section

Administrative Section

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