HomeMy WebLinkAboutskills-form-20170701State of California EMT Skills Competency Verification Form EMSA – SCV (01/17) See attached for instructions for completion
This section is to be filled out by the EMT whose skills are being verified: 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.
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.
Skill Verified Verifiers Information
1. Trauma Assessment
2. Medical Assessment
3. Bag-Valve-Mask Ventilation
4. Oxygen Administration
5. Cardiac Arrest Management w/ AED
6. Hemorrhage Control & Shock Management
Name of Verifier: Date of Verification:
(Signature of Verification)
Approval to Verify from: Cert./License Info. of Verifier:
Seated
8. Penetrating Chest Injury
9. Epinephrine & Naloxone Administration
10. Childbirth & Neonatal Resuscitation
State of California EMT Skills Competency Verification Form EMSA – SCV (01/17)
INSTRUCTIONS FOR COMPLETION OF EMT SKILLS COMPETENCY VERIFICATION FORM
1. A completed EMT Skills Verification Form (EMSA-SCV 01/17) is required for those individuals who are
either renewing or reinstating their EMT certification. This verification form must accompany the application.
2. Verification of skills competency shall be accepted as valid to apply for EMT renewal or reinstatement for a maximum of two (2) years from the date of skill verification.
3. The EMT that is being skills tested shall provide their complete name as shown on their California EMT certification, the EMT certificate number and signature in the spaces provided.
4. Verification of Competency
Once skills competency has been demonstrated by direct observation of an actual or simulated patient contact, i.e. skills station, the individual verifying competency shall:
a. Sign the EMT Skills Competency Verification Form for that skill.
b. Print their name on the EMT Skills Competency Verification Form for that skill.
c. Enter the date that the individual demonstrated the competency of the skill.
d. Provide the name of the organization that has approved them to verify skills.
e. Provide their certification or license type and number.
5. In order to be an approved skills verifier you must meet the following qualifications:
a. Be currently licensed or certified as an EMT, AEMT, Paramedic, Registered Nurse, Physician Assistant, or Physician, and
b. Be approved to verify by:
• EMT training program, or
• AEMT training program, or
• Paramedic training program, or
• Continuing education providers, or
• EMS service provider (including but limited to public safety agencies, private ambulance providers, and other EMS providers).