Emt Skills Competency Verification Form - Emsa State Of California
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2State of California
EMT Skills Competency Verification Form
EMSA – SCV (01/17)
See attached for instructions for completion
This section is to be filled out by the EMT whose skills are being verified:
I certify that I have performed the below listed skills before an approved verifier and have been found competent to perform
these skills in the field.
Name as shown on California EMT Certificate
EMT Certificate Number
Signature
This section is to be filled out by an approved Verifier (see instructions for information on approved Verifiers).
By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is
competent in the skills below.
Skill Verified
Verifiers Information
1. Trauma Assessment
Name of Verifier:
Date of Verification:
Approval to Verify from:
Cert./License Info. of Verifier:
(Signature of Verification)
2. Medical Assessment
Name of Verifier:
Date of Verification:
Approval to Verify from:
Cert./License Info. of Verifier:
(Signature of Verification)
3. Bag-Valve-Mask Ventilation
Name of Verifier:
Date of Verification:
Approval to Verify from:
Cert./License Info. of Verifier:
(Signature of Verification)
4. Oxygen Administration
Name of Verifier:
Date of Verification:
Approval to Verify from:
Cert./License Info. of Verifier:
(Signature of Verification)
5. Cardiac Arrest Management w/ AED
Name of Verifier:
Date of Verification:
Approval to Verify from:
Cert./License Info. of Verifier:
(Signature of Verification)
6. Hemorrhage Control & Shock
Name of Verifier:
Date of Verification:
Management
Approval to Verify from:
Cert./License Info. of Verifier:
(Signature of Verification)
7. Spinal Motion Restriction- Supine &
Name of Verifier:
Date of Verification:
Seated
Approval to Verify from:
Cert./License Info. of Verifier:
(Signature of Verification)
8. Penetrating Chest Injury
Name of Verifier:
Date of Verification:
Approval to Verify from:
Cert./License Info. of Verifier:
(Signature of Verification)
9. Epinephrine & Naloxone
Name of Verifier:
Date of Verification:
Administration
Approval to Verify from:
Cert./License Info. of Verifier:
(Signature of Verification)
10. Childbirth & Neonatal Resuscitation
Name of Verifier:
Date of Verification:
Approval to Verify from:
Cert./License Info. of Verifier:
(Signature of Verification)
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