Emr Skills Verification Form (Page 2 of 2) in pdf

Emr Skills Verification Form Page 2

Instructions for Completion of EMR Skills Verification Form

A completed EMR Skills Verification Form is required to be submitted prior to issuance of a

certification care.

1a. Name of Certificate Holder: Provide the complete name, last name first, of the EMR who

is demonstrating the skills.

1b. License Number: Provide the EMR’s certification number.

1c. Employer: Provide the name of the EMR’s employer.

1d. Signature: Signature of the EMR being evaluated. By signing this section, the EMR is

verifying that the information contained on this form is accurate and that the EMR has

demonstrated competency in the skills listed to a qualified evaluator.

Verification of Competency

1. Affiliation: Provide the name of the EMS service provider that the qualified individual

who is verifying competency is affiliated with.

2. Once competency has been demonstrated by direct observation of an actual or

simulated patient contact, (i.e. skills station), the individual verifying competency shall

sign the EMR Skills Verification Form for that skill.

3. Qualified individuals who verify skills competency shall be currently certified as an

EMT-I or licensed as Paramedic. Each provider shall keep a current list of designated

individuals on file with the San Joaquin County EMS Agency.

4. License Number: Provide the license number of the individual verifying competency.

5. Date: Enter the date that the individual demonstrated competency in each skill.

6. Print Name: Print the name of the individual verifying competency in the skill.

Effective: July 1, 2010

Page 2 of 2

EMS Agency Form #2210A

Emr Skills Verification Form Page 2