California Skills Verification Form (Multiple Instructors Signing)

EMT Section (Person Performing 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 below.

Name as shown on California EMT Certificate *

First

Last

Email *

EMT Certificate Number (If Applicable) *

Verifier Section (Instructors Evaluating the Skills)

This section is to be filled out by an approved Verifier (see instructions for information on approved Verifiers).

Trauma Assessment Verification

By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is competent in Trauma Assessment.

Name of Verifier *

First

Last

Date of Verification *

Verifier Location *

Cert./License Info. of Verifier *

Approval to Verify From *

Approval Section Date

Medical Assessment Verification

By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is competent in Medical Assessment.

Name of Verifier *

First

Last

Date of Verification *

Verifier Location *

Cert./License Info. of Verifier *

Approval to Verify From *

Bag-Valve-Mask Ventilation

By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is competent in Bag-Valve-Mask Ventilation.

Name of Verifier *

First

Last

Date of Verification *

Verifier Location *

Cert./License Info. of Verifier *

Approval to Verify From *

Oxygen Administration

By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is competent in Oxygen Administration.

Name of Verifier *

First

Last

Date of Verification *

Verifier Location *

Cert./License Info. of Verifier *

Approval to Verify From *

Cardiac Arrest Management with AED

By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is competent in Cardiac Arrest Management with AED.

Name of Verifier *

First

Last

Date of Verification *

Verifier Location *

Cert./License Info. of Verifier *

Approval to Verify From *

Hemorrhage Control & Shock Management

By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is competent in Hemorrhage Control & Shock Management.

Name of Verifier *

First

Last

Date of Verification *

Verifier Location *

Cert./License Info. of Verifier *

Approval to Verify From *

Spinal Motion Restriction - Supine & Seated

By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is competent in Spinal Motion Restriction - Supine & Seated.

Name of Verifier *

First

Last

Date of Verification *

Verifier Location *

Cert./License Info. of Verifier *

Approval to Verify From *

Penetrating Chest Injury

By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is competent in Penetrating Chest Injury.

Name of Verifier *

First

Last

Date of Verification *

Verifier Location *

Cert./License Info. of Verifier *

Approval to Verify From *

Epinephrine & Naloxone Administration

By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is competent in Epinephrine & Naloxone Administration.

Name of Verifier *

First

Last

Date of Verification *

Verifier Location *

Cert./License Info. of Verifier *

Approval to Verify From *

Childbirth & Neonatal Resuscitation

By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is competent in Epinephrine & Naloxone Administration.

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 (Instructors Evaluating the Skills)

Trauma Assessment Verification

Medical Assessment Verification

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

Childbirth & Neonatal Resuscitation

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