Skills Competency Verification Form - State Of California Emsa
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2State of California
EMT Skills Competency Verification Form
EMSA – SCV (08/10)
See back of form for instructions for completion
1a. Name as shown on EMT-I Certificate
1b. Certificate Number
1c. Certifying Authority
Skill
Verification of Competency
1. Patient examination, trauma patient;
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
2. Patient examination, medical patient
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
3. Airway emergencies
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
4. Breathing emergencies
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
5. AED and CPR
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
6. Circulation emergencies
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
7. Neurological emergencies
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
8. Soft tissue injury
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
9. Musculoskeletal injury
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
10. Obstetrical emergencies
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
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Parent category: Life