PADI Open Water Diver Course Record and Referral Form

A. CONFINED WATER DIVES B. KNOWLEDGE DEVELOPMENT Course option: £ RDP Table £ eRDPml £ Computer only
Date Completed Instructor** Date Completed Completed Passed Viewed Open Instructor**
Student Name___________________________________________ Day / Month / Year Initials PADI # Day / Month / Year KR Quiz/Exam Water Video Initials PADI #
CW 1* ________ / ________ / ________ ________ #_________ Section 1 ________ / ________ / ________ £ __________ £ __________ # ___________
Birth Date_______ / _______ / _______ Sex £ M £ F
Day Month Year CW 2 ________ / ________ / ________ ________ #_________ Section 2 ________ / ________ / ________ £ __________ £ __________ # ___________
CW 3 ________ / ________ / ________ ________ #_________ Section 3 ________ / ________ / ________ £ __________ £ __________ # ___________
Mailing address__________________________________________
Street CW 4 ________ / ________ / ________ ________ #_________ Section 4 ________ / ________ / ________ £ __________ £ __________ # ___________
_______________________________________________________ Section 5 ________ / ________ / ________ £ __________ £ __________ # ___________
CW 5 ________ / ________ / ________ ________ #_________
City State/Province Country Zip/Postal Code OR eLearning
*DSD with all CW Dive 1 skills = Open Water Diver CW Dive 1 Quick Review ________ / ________ / ________ £ __________ £ __________ # ___________
(Note: If all above Knowledge Development sessions have been completed by one instructor, only one signature required)
Phone Home (______)_____________________________ Waterskills Assessment
All Knowledge Development sessions listed above have been completed, Quizzes/Exams passed.
Business (______)_____________________________ 200 metre/yard Swim OR 300 metre/yard Mask/Snorkel/Fin Swim
________ / ________ / ________ ________ #_________ Instructor Signature____________________________________ #______________ Date___ ______ / ______ / ______
Fax (______)_____________________________ Day Month Year
Email___________________________________________________
10 Minute Survival Float* C. OPEN WATER DIVES
________ / ________ / ________ ________ #_________ Date Completed Instructor** Date Completed Instructor**
Day / Month / Year Initials PADI # Day / Month / Year Initials PADI #
All PADI Instructors who initial this document must comple- Dive 1 ______ / ______ / ______ _______ #_________ Dive 3 ______ / ______ / ______ _______ #_________
te an identification section below. Note: Attach additional sheet for Confined Water Dive Flexible Skills
other PADI Instructor information if necessary. Equipment Preparation and Care* Dive 2 ______ / ______ / ______ _______ #_________ Dive 4 ______ / ______ / ______ _______ #_________
________ / ________ / ________ ________ #_________ Open Water Dive Flexible Skills – These skills may be completed during any Open Water Training Dive.
PADI Instructor___________________________________________
Disconnect Low Pressure Inflator Hose* Completed on Instructor Initials** PADI#
Signature_______________________________________________ 1. Cramp Removal* Dive #__________ ________ #___________
________ / ________ / ________ ________ #_________
PADI No._____________ Dive Center/Resort No.______________ 2. Snorkel/Regulator Exchange* Dive #__________ ________ #___________
Loose Cylinder Band 3. Inflatable Signal Tube/DSMB Deployment* Dive #__________ ________ #___________
Date_______ / _______ / _______
Day Month Year ________ / ________ / ________ ________ #_________ 4. Emergency Weight Drop (or in CW)* Dive #__________ ________ #___________
5. Surface Swim with Compass Dive #__________ ________ #___________
Phone Home (______)_____________________________ Weight System Removal and Replacement (surface)*
6. Tired Diver Tow Dive #__________ ________ #___________
________ / ________ / ________ ________ #_________
Fax (______)_____________________________ 7. Remove/Replace Scuba (surface) Dive #__________ ________ #___________
Emergency Weight Drop (or in OW)* 8. Remove/Replace Weights (surface) Dive #__________ ________ #___________
Email___________________________________________________
________ / ________ / ________ ________ #_________ 9. CESA (Dive 2, 3 or 4) Dive #__________ ________ #___________
10. UW Compass Navigation (Dive 2, 3 or 4) Dive #__________ ________ #___________
PADI Instructor___________________________________________
Skin Diving Skills (Note: If all above Dive Flexible Skills have been completed by one instructor, only one signature is required)
Signature_______________________________________________ ________ / ________ / ________ ________ #_________ All Open Water Dive Flexible Skills listed above have been completed.
PADI No._____________ Dive Center/Resort No.______________ Instructor Signature____________________________________ #_____________ Date________ / ________ / ________
Dry Suit Orientation Day Month Year
Date_______ / _______ / _______ ________ / ________ / ________ ________ #_________
Day Month Year Student Statement: I understand the training requirements for this course and have successfully completed
(Note: If all Confined Water Dives, Confined Water Dive Flexible Skills and Wa- all certification requirements. I am adequately prepared to dive in areas and under conditions similar to those
Phone Home (______)_____________________________ terskills Assessment have been completed by one instructor, only one signature in which I was trained. I realize that additional training is recommended for participation in specialty diving
required.) activities, in other geographical areas, and after periods of inactivity that exceed six months. I agree to abide
Fax (______)_____________________________ by PADI’s Standard Safe Diving Practices.
All Confined Water Dives, Confined Water Dive Flexible Skills and
Email___________________________________________________ Waterskills Assessment have been completed. Student Signature___________________________________________________ Date________ / ________ / ________
Day Month Year
When referring a PADI Scuba Diver/Open Water Diver student: Instructor Signature___________________________________________
All requirements for certification as a PADI Scuba Diver have been met (completion of Knowledge Devel-
a. Fill in the diver and PADI Instructor information and note appropriate opment sessions 1, 2, 3 Confined Water Dives 1, 2, 3 Open Water Dives 1, 2 and all dive flexible skills marked
areas of training completed. PADI #____________________ Date________ / ________ / ________ with an asterisk *).
Day Month Year
b. Attach a copy of the diver’s PADI Medical Statement to this form.
Instructor Signature____________________________________ #_____________ Date________ / ________ / ________
c. Advise the diver of the need for a photo for certification card processing. **I certify that this student has satisfactorily completed this skill/ Day Month Year
d. Encourage the diver to complete training as soon as possible and explain section/dive as outlined in the PADI Instructor Manual. I am a
that this form is only valid for one year from the last training section PADI Instructor renewed in Teaching status for the current year. All requirements for certification as a PADI Open Water Diver have been met.
completion date. Instructor Signature____________________________________ #_____________ Date________ / ________ / ________
Day Month Year

Product No. 10056 (Rev. 01/15) Version 3.08 © PADI 2014