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Get Emt Skills Competency Verification Form

State of California EMT-1 Skills Competency Verification Form EMSA SCV 07/03 1a. Name as shown on EMT-1 Certificate 1b. Certificate Number 1c* Signature 1d. Certifying Authority 1e. Date I certify under the penalty of perjury that the information contained on this form is accurate. Skill Verification of Competency 1. Patient examination trauma patient Affiliation Date Signature of Person Verifying Competency Print Name Certification / License Number 3. Airway emergencies 4. Breathing emergencies 5. Automated external defibrillation 6. Circulation emergencies 7. Neurological emergencies 8. Soft tissue injury 9. Musculoskeletal injury 10. Obstetrical emergencies. Certificate Number 1c* Signature 1d. Certifying Authority 1e. Date I certify under the penalty of perjury that the information contained on this form is accurate. Skill Verification of Competency 1. Patient examination trauma patient Affiliation Date Signature of Person Verifying Competency Print Name Certification / License Number 3. Skill Verification of Competency 1. Patient examination trauma patient Affiliation Date Signature of Person Verifying Competency Print Name Certification / License Number 3. Airway emergencies 4. Breathing emergencies 5. Automated external defibrillation 6. Circulation emergencies 7. Airway emergencies 4. Breathing emergencies 5. Automated external defibrillation 6. Circulation emergencies 7. Neurological emergencies 8. Soft tissue injury 9. Musculoskeletal injury 10. Obstetrical emergencies. Certificate Number 1c* Signature 1d. Certifying Authority 1e. Date I certify under the penalty of perjury that the information contained on this form is accurate. Skill Verification of Competency 1. Patient examination trauma patient Affiliation Date Signature of Person Verifying Competency Print Name Certification / License Number 3. Airway emergencies 4. Breathing emergencies 5. Automated external defibrillation 6. Circulation emergencies 7. Skill Verification of Competency 1. Patient examination trauma patient Affiliation Date Signature of Person Verifying Competency Print Name Certification / License Number 3. Airway emergencies 4. Breathing emergencies 5. Automated external defibrillation 6. Circulation emergencies 7. Neurological emergencies 8. Soft tissue injury 9. Musculoskeletal injury 10. Obstetrical emergencies.

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