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I certify that I have performed the below (HSA)

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State 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.
Name as shown on California EMT Certificate
EMT Certificate Number
Signature
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
Name of Verifier:
Date of Verification:
(Signature of Verification)
Approval to Verify from:
Cert./License Info. of Verifier:
2. Medical Assessment
Name of Verifier:
Date of Verification:
(Signature of Verification)
Approval to Verify from:
Cert./License Info. of Verifier:
3. Bag-Valve-Mask Ventilation
Name of Verifier:
Date of Verification:
(Signature of Verification)
Approval to Verify from:
Cert./License Info. of Verifier:
4. Oxygen Administration
Name of Verifier:
Date of Verification:
(Signature of Verification)
Approval to Verify from:
Cert./License Info. of Verifier:
5. Cardiac Arrest Management w/ AED
Name of Verifier:
Date of Verification:
(Signature of Verification)
Approval to Verify from:
Cert./License Info. of Verifier:
6. Hemorrhage Control & Shock
Management
Name of Verifier:
Date of Verification:
(Signature of Verification)
Approval to Verify from:
Cert./License Info. of Verifier:
7. Spinal Motion Restriction- Supine &
Seated
Name of Verifier:
Date of Verification:
(Signature of Verification)
Approval to Verify from:
Cert./License Info. of Verifier:
8. Penetrating Chest Injury
Name of Verifier:
Date of Verification:
(Signature of Verification)
Approval to Verify from:
Cert./License Info. of Verifier:
9. Epinephrine & Naloxone
Administration
Name of Verifier:
Date of Verification:
(Signature of Verification)
Approval to Verify from:
Cert./License Info. of Verifier:
10. Childbirth & Neonatal Resuscitation
Name of Verifier:
Date of Verification:
(Signature of Verification)
Approval to Verify from:
Cert./License Info. of Verifier:
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).
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I certify that I have performed the below (HSA)

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Completed 21 February 2021

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