Candidate Name: _________________________________________ Date: ______________________

Examiner Name and Signature: _________________________________________________________

Time Started: __________ Time Ended: __________ Points: _____/18 PASS/FAIL (Circle One)

Points Possible Points Awarded
Takes or verbalizes appropriate PPE precautions 1
Prepares Medication
  Right patient, Right Medication, Right Dose, Right Route, Right time 5
Administration of Epinephrine
   Explain procedure to patient
   Remove medication from the package. DO NOT TEST THE DEVICE 1
   Select and prepare appropriate injection site 1
   Hold device without putting fingers on either end of auto-injector 1
   Remove safety device from auto-injector 1
   Securely Immobilize leg particularly in children 1
   Place tip of auto-injector against patients lateral mid-thigh at 90 degree angle 1
  In quick motion, presses hard onto thigh until auto-injector mechanism functions, holds injector in place for 3-10 seconds (Device Dependent) 1
  Withdraw auto-injector and apply pressure to injection site using dressing/bandage. Massage area for 10 seconds 1
   Dispose of auto-injector in a sharps container 1
Evaluation and Support
  Obtain Vital signs 1
  Monitor patient for desired effects 1
  Monitor patient for adverse effects 1

Points Possible: 18                    Total Points Awarded_______________

Critical Criteria

____ Failure to take appropriate PPE precautions

____ Failure to dispose of the needle in the proper container at the proper time

____ Failure to correctly prepare site and administer medication appropriately

____ Failure to reassess the patient and provide supportive care

____ Failure to manage patient as a competent EMT

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