Sample Self AssessmentLIFEPAK® 1000 Defibrillator

Name Facility

Dept. Date

Marking “yes” indicates I understand the information provided during the defibrillator training session and know how to:

SkIll YeS No CoMMeNtS/RefeReNCeS

AeD Procedure:

Recognize cardiopulmonary arrest.

Call for help and start CPR.

Press On/Off to turn on the defibrillator.

Prepare patient for therapy electrode (hands-free pad) placement

according to package directions.

Confirm therapy electrode connection to defibrillator.

Follow screen messages and voice prompts provided by the defibrillator.

Confirm no one is touching patient during analysis.

Shock Advised:

Confirm no one is touching the patient prior to pressing the button.

Press the button then start CPR per screen messages and voice prompts.

No Shock Advised:

Resume CPR immediately.

Follow screen messages and voice prompts provided by the defibrillator.

Manual Mode:

Access and use Manual Mode if authorized.

eCG Mode (optional):

Use ECG mode and change the therapy cable to ECG cable.

Recognize the “Connect Therapy Electrodes” message and take appropriate action.

Maintenance and testing:

Identify symbols in the readiness display and know what they represent.

Identify battery status using the battery indicator.

Employee signature Date Educator or supervisor Date

For additional information, please consult the Operating Instructions.

Operating Instructions can be found (Location)

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GDR 3306342_A