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SKILLS VERIFICATION FORM

Skills Evaluator:

This healthcare professional has successfully completed the nationally accredited, online training program in
emergency resuscitation offered through the ACLS Certification Institute.

This training meets the emergency resuscitation guidelines of the Joint Commission on the Accreditation of
Healthcare Organizations (JCAHO) and the National Registry of Emergency Medical Technicians (NREMT) as it is
built on the most current ECC national guidelines for appropriate BLS, ACLS, PALS and/or NRP care.

By completing this form, you verify that this student has successfully completed the skills evaluation for
emergency resuscitation of a patient in cardiac and/or respiratory distress/arrest as required by your hospital or
agency.

This documentation will remain a permanent part of the student’s record and is required before an official course
completion card can be issued. This form must be signed and returned with the accompanying skills evaluation
form.

Your signature on this form verifies that you provided a skills evaluation to the student to verify clinical
competence based off the course(s) the student successfully completed.

Note: The student must provide you with documentation that he/she has successfully completed the didactic
portion of the course prior to completing a skills evaluation.

Upon completion of the skills evaluation, all forms should be scanned and emailed to: skills@acls.com

Skills Evaluator Signature: Skills Evaluator Address:

Skills Evaluator Name: (PRINTED) Skills Evaluator Phone:

Skills Evaluator Company: Skills Evaluator Email:

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Student Name:

Evaluator Name:

Evaluator Position, Organization:

This skills evaluation allows a student to show competency in basic life support techniques in accordance
with the most current ECC guidelines as published by the American Heart Association (AHA).

Please note that the student MUST provide documentation that they have successfully completed the
didactic training prior to the skills evaluation. It should also be noted that audits are performed to ensure
skills evaluations are conducted in a professional manner. Any student found cheating will not be awarded
a certification card.

If the student misses the critical performance steps as listed, remediation needs to be completed. Please
explain in the comments that remediation was provided and whether it was successful.

SCENARIO:
You are dispatched to a 48 yr old female who was at work and collapsed. Bystanders who called are
unsure of the female’s status.

1- AND 2-RESCUER ADULT BLS WITH AED

EVALUATOR
INITIAL WHEN
CRITICAL PERFORMANCE STEPS
PERFORMED
CORRECTLY

First rescuer:

Assesses victim.

1 Checks for unresponsiveness.

Activates ERS, and calls for AED.

2 Checks for no breathing or inadequate breathing (gasping).

Checks for pulse for at least 5 seconds by not longer than 10 seconds. (Breathing can
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be checked at the same time.)

Delivers high-quality CPR compression rate (100-120), correct depth, correct hand
placement. Allows for complete chest recoil, minimizes interruptions (less than 10
seconds).
4
Compressions not interrupted until AED analyzing rhythm.

Compressions returned immediately after shock/no shock advised.

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Second rescuer returns with AED and the two initiate prompt and proper use of AED
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with CPR.

Second rescuer:

Turns AED on.


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Places proper-sized pads for victim’s age in proper position.

Clears rescuers for AED to analyze, directs rescuers to switch out for compressions
while AED analyzes.
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Clears rescuers to deliver shock.

8 Resumes chest compressions immediately after shock delivery.

Provides effective breaths.

Initially this will be the second rescuer, after AED is placed but before the first round (5
cycles) of compressions is over, when the rescuers switch this will become the first rescuer.

Opens airway adequately (either head tilt chin lift or jaw thrust if trauma is suspected).
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Delivers each breath over 1 second for 2 breaths.

Delivers breaths that produce visible chest rise.

Avoids excessive ventilation.

CRITICAL CRITERIA:
c Pass Comments

Adequate depth c Remediation

c Fail

c Pass Comments

Adequate placement c Remediation

c Fail

c Pass Comments

Adequate rate c Remediation

c Fail

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c Pass Comments
Choosing the incorrect way to open airway c Remediation
(trauma vs. medical)
c Fail

Skills evaluator signature affirms that the skills tests were performed according to ECC guidelines.

Signature of evaluator Printed name of evaluator

SCENARIO:
You are dispatched for an infant that is not breathing. On arrival, mother states pt was found lying
in crib not breathing.

Circulation: No brachial pulse present, skin pale, and cyanotic


Airway: Clear, no obstructions noted
Breathing: No spontaneous respirations

1- AND 2-RESCUER INFANT BLS WITH AED

EVALUATOR
INITIAL WHEN
CRITICAL PERFORMANCE STEPS
PERFORMED
CORRECTLY

First rescuer:

Assesses victim.

Checks for unresponsiveness.


1
Activates ERS, and calls for AED. (Can use cell phone while checking
unresponsiveness at the same time.)

2 Checks for no breathing or inadequate breathing (gasping).

Checks for pulse for at least 5 seconds but not longer than 10 seconds. (Breathing can
be checked at the same time.)
3
***Checks brachial pulse for infant.

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Delivers high-quality chest compressions during 1-rescuer CPR.

Correct placement of hands/fingers in center of chest, 2 fingers just below the nipple line.

Compression rate of 100-120/min.

Adequate depth for age.


4
Infant: at least one third the depth of the chest (approximately 1½ inches [4 cm])

Complete chest recoil after each compression.

Minimizes interruptions in compressions.

Can give 2 breaths with pocket mask.

Second Rescuer:

5 Switches at appropriate intervals (5 cycles of CPR).

Provides effective breaths with bag mask device during 2-rescuer CPR:

Opens airway adequately.

6 Delivers each breath over 1 second.

Delivers breaths that produce visible chest rise.

Avoids excessive ventilation.

Provides high-quality chest compressions during 2-rescuer CPR.

Correct placement of hands/fingers for 2 rescuers is center of chest, 2 thumb-


encircling hands just below the nipple line.

Compression rate of 100-120/min.

7 Adequate depth for age.

*Infant: at least on third the depth of the chest.

*Complete chest recoil.

Appropriate ratio for age and number of rescuers:


2 rescuers = 15 compressions to 2 breaths

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CRITICAL CRITERIA:
c Pass Comments

Inadequate depth c Remediation

c Fail

c Pass Comments

Inadequate placement c Remediation

c Fail

c Pass Comments

Inadequate rate c Remediation

c Fail

c Pass Comments
Choosing the incorrect way to open airway c Remediation
(trauma vs. medical)
c Fail

Skills evaluator signature affirms that the skills tests were performed according to ECC guidelines.

Signature of evaluator Printed name of evaluator

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