California Skills Verification Form (Single Instructor Signing)

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EMT Section (Person Performing the Skills)

Name as shown on California EMT Certificate

First

Last

From Date Verify

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 (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

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 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. 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 (Person Evaluating the Skills)

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