Candidate Name: _________________________________________ Date: ______________________

Examiner Name and Signature: _________________________________________________________

Time Started: __________ Time Ended: __________ Points: _____/12 PASS/FAIL (Circle One)

Points Possible Points Awarded
General Impression
  • Conscious/unconscious/altered
  • Breathing adequate/labored/unlabored/absent
  • Skin color
  • Presence of significant bodily fluids
  • States General Impression is poor or good
Level of Consciousness (AVPU)
  • Alert
  • Verbal
  • Pain
  • Unresponsive
Chief complaint/ Life threats 1
Assess and manage X-Airway 1
Assess and manage Breathing 1
Assess and manage Circulation 1
Assessed Disability 1
Expose, Examine and protect from Environment
Identifies Priority patients
Makes transport decision 1

                                          Total Points Awarded_______________

Critical Criteria

____ Failure to take appropriate PPE precautions

____ Failure to manage patient competently

____ Uses or orders a dangerous or inappropriate intervention

Notes: ____________________________________________________________________________________________


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