Course Training Documentation and Referral Form

Student Name______Birth Date (D/M/Y) ______/______/______Student Mailing Address______City______State/Province______Country______Zip/Postal Code______Phone (______) ______Business Phone (______)______Fax (______)______Email______Knowledge Review Date Initials Completed Completed Student / Instructor PADI No. I. Knowledge Development Presentations Presentation One q _____/_____/______/______Presentation Two q _____/_____/______/______Presentation Three q _____/_____/______/______Presentation Four q _____/_____/______/______Presentation Five q _____/_____/______/______

II. Rescue Training Exercises – Indicate location of Training Exercises Pool Open Water Self Rescue Review q q _____/_____/______/______Exercise 1 – Tired Diver q q _____/_____/______/______Exercise 2 – Panicked Diver q q _____/_____/______/______Exercise 3 – Response from Shore, Boat q q _____/_____/______/______Excerise 4 – Distressed Diver Underwater q q _____/_____/______/______Exercise 5 – Missing Diver q q _____/_____/______/______Exercise 6 – Surfacing the Unresponsive Diver q q _____/_____/______/______Exercise 7 – Unconscious Diver at the Surface q q _____/_____/______/______Exercise 8 – Exiting the Unresponsive Diver q q _____/_____/______/______Exercise 9 – for -related q q _____/_____/______/______Injuries and Administration Exercise 10 – Response from Shore/Boat q q _____/_____/______/______Unresponsive Diver

III. Open Water Rescue Scenarios Open Water Rescue Scenario One _____/_____/______/______Open Water Rescue Scenario Two _____/_____/______/______Final Examination _____/_____/______/______

Emergency First Response Primary Care (CPR) and Secondary Care (First Aid) PADI Member Name______Signature______PADI No. ______Dive Center/Resort No. ______Date (D/M/Y) ______/______/______Phone (______)______Fax (______)______Email ______

PADI Instructors Involved in Training PADI Instructor Name______Signature______PADI No. ______Dive Center/Resort No. ______Date (D/M/Y) ______/______/______Phone (______)______Fax (______)______Email ______

PADI Instructor Name______Signature______PADI No. ______Dive Center/Resort No. ______Date (D/M/Y) ______/______/______Phone (______)______Fax (______)______Email ______

Product No. 10295 (Rev. 5/10) Version 2.04 © PADI 2010 Referral Procedure The purpose of this procedure is to allow a student diver 4. Retain this form until you have completed all required to complete a PADI Rescue Diver course with more than training sessions. one PADI Instructor. A PADI Rescue Diver student may be 5. The PADI Instructor(s) continuing your training will referred to another PADI Instructor after completing any preassess your skills and knowledge and review any- knowledge development session, training exercise and/ thing that may be unclear. or open water rescue scenario. The student diver must 6. Upon completion of all required training, you and the complete the entire session, exercise or scenario PADI Instructor will complete a Positive Identification to receive referral credit for that session, exercise, Card (PIC) envelope. This envelope must be submitted or scenario. to PADI along with your photo to obtain a certifica- tion card. To refer a PADI Rescue Diver student, use this PADI Rescue Diver Course Training Documentation and Important Points for the Referring Instructor(s) Referral Form found in the Appendix of the PADI Rescue 1. Fill in the requested information on this form, includ- Diver Instructor Guide. This form, along with ’s ing the diver’s name and address and your contact completed Medical Statement, may be given directly to information. Also, fill in the appropriate areas of the diver to continue PADI Rescue with training completed before referring the diver. another PADI Instructor. 2. Attach a copy of the diver’s PADI Medical Statement to this form. Also advise the diver of the need for a A PADI Rescue Diver Course Training photo for certification card processing. Documentation and Referral Form is valid for 12 3. Give the diver the entire form. If possible, assist the months from the last training segment comple- diver in making arrangements with a PADI Dive tion date. Prior to conducting a Rescue Diver Center, PADI Resort or PADI Instructor for completing exercise for a referred student, a preassessment training as additional local requirements may apply. and the administrative requirements as outlined Keep a photocopy for your records. in PADI “General Standards and Procedures” 4. Encourage the diver to complete the training as soon must be completed (i.e. signed Medical Statement, as possible. Advise the diver that the form is only Standard Safe Diving Practices Statement valid for 12 months after the last training session of Understanding, and Liability Release and completion date. Assumption of Agreement.) All PADI Instructors involved in the referral process, initial training or subsequent training, must retain a Important Points for the Receiving Instructor(s) copy of the administrative paperwork, as well as 1. Preassess the diver’s knowledge and skills. Be certain the Rescue Diver Course Training Documentation that the diver is adequately prepared to continue and Referral Form. The instructor who conducts training. the student diver’s final open water training 2. A diver may be referred after completing any knowl- ensures that the diver has met all certification edge development session, training exercise and/or requirements and certifies the diver. open water rescue scenario. 3. Upon completion of each component, initial and date When you receive a Rescue Diver referral student, you this form in the appropriate area. The diver retains may check the status of PADI Instructors who previously the referral form until the completion of all certifica- signed off on the training documentation form by calling tion requirements. Retain a photocopy of this form for your PADI Office. your records. 4. If you conduct the final open water rescue scenario Important Points for the Diver you are the certifying instructor. Complete and submit a PADI Positive Identification Card (PIC) envelope to 1. Verify that the PADI Instructor(s) who will complete PADI for processing. Retain a copy of the completed your training is in Teaching Status. referral form for your records and forward a copy to 2. Take this form, along with a copy of your completed the original instructor for his records. PADI Medical Statement and a photograph to the PADI , PADI Resort or PADI Instructor com- pleting your training. 3. This referral form is valid for 12 months after the last QUESTIONS – About how to use the form? training session completion date, however you should Call PADI. complete your training as soon as possible.