BLS Precourse Self-Assessment Questionnaire Form
Complete this self-assessment to help identify your current BLS knowledge and confidence before class. Use the exact title consistently throughout the form.
Learner Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Training Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
BLS Background and Confidence
Prior BLS/CPR Experience Level
*
None
Basic exposure only
Recently certified
Experienced practitioner
Other
Current Confidence in BLS Skills
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
How Recently You Last Completed BLS/CPR Training
*
Please Select
Within the last 6 months
6-12 months ago
1-2 years ago
More than 2 years ago
Never completed BLS/CPR training
Other
Skills Self-Assessment
Confidence in recognizing cardiac arrest
*
Rows
Not confident
Slightly confident
Moderately confident
Very confident
Extremely confident
Recognizing cardiac arrest
1
2
3
4
5
Confidence in activating emergency response
*
Rows
Not confident
Slightly confident
Moderately confident
Very confident
Extremely confident
Activating emergency response
6
7
8
9
10
Confidence in core BLS skills
*
Rows
Not confident
Slightly confident
Moderately confident
Very confident
Extremely confident
Chest compressions
11
12
13
14
15
Rescue breaths
16
17
18
19
20
AED use
21
22
23
24
25
Scene safety
26
27
28
29
30
Top area for improvement
Submit Self-Assessment
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