Research Project Instructions

COMPARISON OF PERCEIVED AND DEMONSTRATED COMPETENCY

Appendix I

Student ID:

CPR Retention Survey Form Thank you for consenting to participate in research regarding CPR skills retention. Please complete the following questions on this survey then fold and hand this paper to the trainer. Results are confidential and are not used in your recertification course in any way. Please described your healthcare licensure and experience (please check all that apply): License Held Yrs of Experience Practice Environment (MedSurg, ER, School RN, etc) □ Registered Nurse _____ _____________________ □ Practical Nurse _____ _____________________ □ EMT _____ _____________________ □ Paramedic _____ _____________________ □ Physician _____ _____________________ □ Fire/Police _____ _____________________ □ Therapist (RT/PT/OT) _____ _____________________ □ Technician / Care Associate _____ _____________________ □ Other: ______________________ _____ _____________________

1. How comfortable are you overall with your BLS skills:

2. With the appropriate equipment how confident would you be managing a cardiac arrest patient by yourself for 2 minutes? □ Very Comfortable

□ Very Comfortable □ Somewhat Comfortable □ Somewhat Uncomfortable □ Very Uncomfortable

□ Somewhat Comfortable □ Somewhat Uncomfortable □ Very Uncomfortable

3. How would you assess your chest compression skills?

4. How would you assess your skill at rescue breathing with a bag-mask device?

□ Excellent □ Good □ Marginal □ Poor

□ Excellent □ Good □ Marginal □ Poor

5. How would you assess your ability to efficiently and safely use an Automated External Defibrillator (AED)?

6. How would you assess your ability to organize and execute all the individual skills used in resuscitation?

□ Excellent □ Good □ Marginal □ Poor

□ Excellent □ Good □ Marginal □ Poor