CPR Quality Evaluation Checklist Form
CPR Quality Evaluation Checklist Form
Evaluator Name
*
First Name
Last Name
Session Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Session Type
*
Please Select
Practice session
Skills assessment
Refresher session
Other
CPR Performer Name
*
First Name
Last Name
Performance Criteria
*
Rows
Meets expectations
Needs improvement
Not observed
Checks scene safety and responsiveness
1
2
3
Calls for help and activates emergency response
4
5
6
Begins compressions promptly
7
8
9
Maintains appropriate compression rate and depth
10
11
12
Allows full chest recoil
13
14
15
Minimizes interruptions
16
17
18
Provides appropriate breaths when applicable
19
20
21
Overall CPR Performance Rating
*
1
2
3
4
5
Observations
Evaluation Outcome
*
Please Select
Meets expectations
Further practice recommended
Follow-up evaluation recommended
Follow-Up Notes
This is a performance review and does not replace clinical judgment.
Submit Evaluation
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