BLS CPR Skills Checklist
Complete this checklist to evaluate BLS CPR performance, technique, and overall competency.
Participant and Session Details
Participant Full Name
*
First Name
Middle Name
Last Name
Role / Job Title or Training Status
*
Organization / Site
*
Evaluator / Instructor Name
*
First Name
Middle Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Training / Class Session ID
BLS CPR Skills Checklist
BLS CPR Skill Items
*
Rows
Not Observed
Needs Improvement
Meets Standard
Scene safety
1
2
3
Checks responsiveness
4
5
6
Activates emergency response
7
8
9
Checks breathing and pulse as appropriate
10
11
12
Correct compression hand placement
13
14
15
Compression rate
16
17
18
Compression depth
19
20
21
Minimizes interruptions
22
23
24
Allows full chest recoil
25
26
27
Effective ventilation technique
28
29
30
Correct compression-to-ventilation ratio
31
32
33
AED retrieval and pad placement
34
35
36
Clear verbal communication
37
38
39
Team coordination
40
41
42
Overall competency result
*
Competent
Not Yet Competent
Total score
Critical errors noted
Failed to check scene safety
Delayed emergency activation
Incorrect compression technique
Inadequate ventilation technique
Incorrect AED use
Poor team communication
Other
Overall evaluator rating
1
2
3
4
5
Scene safety
Not Observed
Needs Improvement
Meets Standard
Checking responsiveness
Not Observed
Needs Improvement
Meets Standard
Compression technique
Not Observed
Needs Improvement
Meets Standard
Ventilation technique
Not Observed
Needs Improvement
Meets Standard
AED use and team coordination
Not Observed
Needs Improvement
Meets Standard
Comments and Final Outcome
Evaluator Comments
*
Remediation or Retraining Needed?
*
Yes
No
Retest Required?
*
Yes
No
Final Competency Decision
*
Competent
Not Yet Competent
Submit
Should be Empty: