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INSTRUCTIONS FOR COMPLETION OF EMT-I SKILLS COMPETENCY VERIFICATION FORM A completed EMT-I Skills Verification Form is required to accompany an EMT-I recertification application for those individuals who are either maintaining EMT-I certification without a lapse or to renew EMT-I certification with a lapse in certification less than one year. 1a. Name of Certificate Holder Provide the complete name, last name first, of the EMT-I certificate holder who is demonstrating skills competency. lb. Certificate Number Provide the EMT-I certification number from the current or lapsed EMT-I certificate of the EMT-I certificate holder who is demonstrating competency. 1c. Signature Signature of the EMT-I certificate holder who is demonstrating competency. By signing this section the EMT-I is verifying that the information contained on this form is accurate and that the EMT-I certificate holder has demonstrated competency in the skills listed to a qualified individual. 1d. Certifying Authority Provide the name of the EMT-I certifying authority for which the individual will be certifying through. Verification of Competency 1. Affiliation - Provide the name of the training program or EMS service provider that the qualified individual who is verifying competency is affiliated with. 2. Once competency has been demonstrated by direct observation of an actual or simulated patient contact, i.e. skills station, the individual verifying competency shall sign the EMT-I Skills Competency Verification Form (EMSA-SCV 07/03) for that skill. 3. Qualified individuals who verify skills competency shall be currently licensed or certified as: An EMT-I, EMT-II, Paramedic, Registered Nurse, Physician Assistant, or Physician and shall be either a qualified instructor designated by an EMS approved training program (EMT-I training program, paramedic training program or continuing education training program) or by a qualified individual designated by an EMS service provider. EMS service providers include, but are not be limited to, public safety agencies, private ambulance providers, and other EMS providers. 4. Certification or License Number— Provide the certification or license number for the individual verifying competency. 5. Date- Enter the date that the individual demonstrates competency in each skill. 6. Print Name— Print the name of the individual verifying competency in the skill. Verification of skills competency shall be valid to apply for EMT-I recertification for a maximum of two years from the date of verification.