California Skills Verification Form (Single Instructor Signing)

EMT Section (Person Performing the Skills)

Name as shown on California EMT Certificate *

First

Last

Email *

EMT Certificate Number (If Applicable) *

Verifier Section (Person Evaluating the Skills)

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: Trauma Assessment, Medical Assessment, Bag-Valve-Mask Ventilation, Oxygen Administration, Cardiac Arrest Management with AED, Hemorrhage Control & Shock Management, Spinal Motion Restriction - Supine & Seated, Penetrating Chest Injury, Epinephrine & Naloxone Administration, and Childbirth & Neonatal Resuscitation.

Name of Verifier *

First

Last

Date of Verification *

Verifier Location *

Cert./License Info. of Verifier *

Approval to Verify From *

EMS University

EMT Section (Person Performing the Skills)

Verifier Section (Person Evaluating the Skills)

Helpful guidance on your EMT Training...