Padi Open Water Diver Course Record And Referral Form
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2PADI Open Water Diver Course Record and Referral Form
B. Knowledge Development
Course option:
RDP Table
eRDP
Computer only
ML
Date Completed
Completed
Passed
Viewed Open
Instructor**
Student Name_____________________________________________ Birth Date _____________
Day/Month/Year
KR
Quiz/Exam
Water Video
Initials
PADI #
Day/Month/Year
Mod 1
____/____/____
______
________#__________
Mailing address____________________________________________________ Sex
M
F
Mod 2
____/____/____
______
________#__________
City_____________________________________ State/Province___________________________
Mod 3
____/____/____
______
________#__________
Country____________________________________________ Zip/Postal Code_______________
Mod 4
____/____/____
______
________#__________
Phone Home (____)_______________________ Business (____)__________________________
Mod 5
____/____/____
______
________#__________
Fax (____)________________________ Email _________________________________________
OR eLearning Quick Review ___/___/___
______
________#__________
(Note: If all above Knowledge Development sessions have been completed by one instructor, only one signature required)
All PADI Instructors who initial this document must complete an identification section below.
All Knowledge Development sessions listed above have been completed, Quizzes/Exams passed.
PADI Instructor__________________________________ Signature_________________________
Instructor Signature _________________________________ #__________ Date ____/____/____
PADI No.________________ Dive Center/Resort No._____________________ Date___________
Day/Month/Year
C. Open Water Dives
Phone No. (____)_________________________ Fax No. (____)_________________________
Date Completed
Instructor **
Date Completed
Instructor **
Day/Month/Year
Initials
PADI #
Day/Month/Year
Initials
PADI #
Email Address __________________________________________________________________
Dive 1 ____/____/____ ______#________
Dive 3 ____/____/____
______#________
PADI Instructor__________________________________ Signature_________________________
Dive 2 ____/____/____ ______#________
Dive 4 ____/____/____
______#________
PADI No.________________ Dive Center/Resort No._____________________ Date___________
Dive Flexible Skills
Day/Month/Year
These skills may be completed during any Open Water Training Dive.
Phone No. (____)_________________________ Fax No. (____)___________________________
Completed
Instructor**
Email Address ____________________________________________________________________
on
Initials
PADI#
1. Cramp Removal
Dive #____
________#__________
Note: Attach additional sheet for other PADI Instructor information if necessary.
2. Tired Diver Tow
Dive #____
________#__________
When referring a PADI Scuba Diver/Open Water Diver student:
3. Surface Swim with Compass
Dive #____
________#__________
a. Fill in the diver and PADI Instructor information and note appropriate areas of training completed.
4. Snorkel/Regulator Exchange
Dive #____
________#__________
b. Attach a copy of the diver’s PADI Medical Statement to this form.
c. Advise the diver of the need for a photo for certification card processing.
5. Safety Stop
Dive #____
________#__________
d. Encourage the diver to complete training as soon as possible and explain that this form is only
6. Remove/Replace Scuba (surface)
Dive #____
________#__________
valid for one year from the last training module completion date.
7. Remove/Replace Weights (surface)
Dive #____
________#__________
Watermanship Assessment
A. Confined Water Dives
8. CESA (Dive 2, 3 or 4)
Dive #____
________#__________
Date Completed
Instructor **
Date Completed
Instructor **
Day/Month/Year
Initials
PADI #
9. UW Compass Navigation (Dive 2, 3 or 4)
Dive #____
________#__________
Day/Month/Year
Initials
PADI #
(Note: If all above Dive Flexible Skills have been completed by one instructor, only one signature is required)
200 metre/yard Swim OR
CW 1* ____/____/____
______ #________
300 metre/yard Mask/Snorkel/Fin Swim
All Dive Flexible Skills listed above have been completed.
____/____/____
______#________
CW 2 ____/____/____
______ #________
Instructor Signature _________________________________ #__________ Date ____/____/____
10 Minute Survival Float
CW 3 ____/____/____
______ #________
____/____/____
______#________
Student Statement: I understand the training requirements for this course and have successfully com-
CW 4 ____/____/____
______ #________
Skin Diving Skills
pleted all certification requirements. I am adequately prepared to dive in areas and under conditions
____/____/____
______#________
similar to those in which I was trained. I realize that additional training is recommended for participation
CW 5 ____/____/____
______ #________
in specialty diving activities, in other geographical areas, and after periods of inactivity that exceed six
Dry Suit Orientation
* DSD with all CW Dive 1 skills = Open Water
____/____/____
______#________
months. I agree to abide by PADI’s Standard Safe Diving Practices.
Diver CW Dive 1
Student Signature ______________________________________________ Date ____/____/____
(Note: If all Confined Water Dives and Watermanship Assessment have been completed by one instructor, only one signature required.)
All requirements for certification as a PADI Scuba Diver have been met (completion of Knowledge De-
All Confined Water Dives listed above and the Watermanship Assessment have been completed.
velopment sessions 1, 2, 3 Confined Water Dives 1, 2, 3 Open Water Dives 1, 2).
Instructor Signature ________________________________ PADI #__________ Date ____/____/____
Instructor Signature _________________________________ #__________ Date ____/____/____
**I certify that this student has satisfactorily completed this skill/module/dive as outlined in the
All requirements for certification as a PADI Open Water Diver have been met.
PADI Instructor Manual. I am a PADI Instructor renewed in Teaching status for the current year.
Instructor Signature _________________________________ #__________ Date ____/____/____
Product No. 10056 (Rev. 1/11) Version 3.07
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