Emr Skills Verification Form
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1
2SAN JOAQUIN COUNTY EMS AGENCY
EMERGENCY MEDICAL RESPONDER SKILLS COMPETENCY VERIFICATION FORM
1a. Name:
1b. Certification Number:
1c. Employer:
1d. EMR Signature:
Skill
Verification of Competency
Affiliation
Date
1. Patient Assessment (including vital
signs)
Signature of Person Verifying Competency
Print Name
Certification / License Number
2. CPR and AED
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
3. Oropharyngeal Airway
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
Affiliation
Date
4. Nasopharyngeal Airway
Signature of Person Verifying Competency
Print Name
Certification / License Number
5. Bag Valve Mask
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
6. Oxygen and oxygen devices (i.e., mask
Affiliation
Date
cannula)
Signature of Person Verifying Competency
Print Name
Certification / License Number
Affiliation
Date
7. Suctioning Techniques and Suctioning
Equipment
Signature of Person Verifying Competency
Print Name
Certification / License Number
Affiliation
Date
8. Splints Soft and Rigid
Signature of Person Verifying Competency
Print Name
Certification / License Number
9. Spinal Immobilization
Affiliation
Date
Signature of Person Verifying Competency
Print Name
Certification / License Number
Affiliation
Date
10. Obstetrical Emergencies
Signature of Person Verifying Competency
Print Name
Certification / License Number
Falsification of reaccreditation documents will result in immediate denial of the application
and a referral to the EMS Authority for disciplinary action.
Effective: July 1, 2010
Page 1 of 2
EMS Agency Form #2210A
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