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) *

EMT Signature

Clear Signature

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.

Verifier Section (Instructors Evaluating the Skills)

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

of Signature Motion

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 *

Signature of Verification *

Clear Signature

By filling out this I certify that I have, through direct observation, verified that the above EMT is competent in Trauma Assessment. I also agree to make an electronic form based on the information provided above of the California Skills Verification form found at https://ems.ca.gov.

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 *

Signature of Verification *

Clear Signature

By filling out this I certify that I have, through direct observation, verified that the above EMT is competent in Medical Assessment. I also agree to make an electronic form based on the information provided above of the California Skills Verification form found at https://ems.ca.gov.

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 *

Signature of Verification *

Clear Signature

By filling out this I certify that I have, through direct observation, verified that the above EMT is competent in Bag-Valve-Mask Ventilation. I also agree to make an electronic form based on the information provided above of the California Skills Verification form found at https://ems.ca.gov.

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 *

Signature of Verification *

Clear Signature

By filling out this I certify that I have, through direct observation, verified that the above EMT is competent in Oxygen Administration. I also agree to make an electronic form based on the information provided above of the California Skills Verification form found at https://ems.ca.gov.

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 *

Signature of Verification *

Clear Signature

By filling out this I certify that I have, through direct observation, verified that the above EMT is competent in Cardiac Arrest Management with AED. I also agree to make an electronic form based on the information provided above of the California Skills Verification form found at https://ems.ca.gov.

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 *

Signature of Verification *

Clear Signature

By filling out this I certify that I have, through direct observation, verified that the above EMT is competent in Hemorrhage Control & Shock Management. I also agree to make an electronic form based on the information provided above of the California Skills Verification form found at https://ems.ca.gov.

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 *

Signature of Verification *

Clear Signature

By filling out this I certify that I have, through direct observation, verified that the above EMT is competent in Spinal Motion Restriction - Supine & Seated. I also agree to make an electronic form based on the information provided above of the California Skills Verification form found at https://ems.ca.gov.

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 *

Signature of Verification *

Clear Signature

By filling out this I certify that I have, through direct observation, verified that the above EMT is competent in Penetrating Chest Injury. I also agree to make an electronic form based on the information provided above of the California Skills Verification form found at https://ems.ca.gov.

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 *

Signature of Verification *

Clear Signature

By filling out this I certify that I have, through direct observation, verified that the above EMT is competent in Epinephrine & Naloxone Administration. I also agree to make an electronic form based on the information provided above of the California Skills Verification form found at https://ems.ca.gov.

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 *

Signature of Verification *

Clear Signature

By filling out this I certify that I have, through direct observation, verified that the above EMT is competent in Childbirth & Neonatal Resuscitation. I also agree to make an electronic form based on the information provided above of the California Skills Verification form found at https://ems.ca.gov.

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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