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ATTACHMENT - A <br /> State of California <br /> EMT-I Skills Competency Verification Form <br /> EMSA—SCV(07/03) '°+u,oax` <br /> See back of form for instructions for completion <br /> la. Name as shown on EMT-I Certificate 1b. Certificate Number 1c. Signature <br /> 1d. Certifying Authority le. Date I certify, under the penalty of perjury,that the <br /> information contained on this form is accurate. <br /> Skill Verification of Competency <br /> 1. Patient examination,trauma patient; Affiliation Date <br /> Signature of Person Verifying Competency Print Name Certification/License Number <br /> 2. Patient examination,medical patient Affiliation Date <br /> Signature of Person Verifying Competency Print Name Certification/License Number <br /> 3.Airway emergencies Affiliation Date <br /> Signature of Person Verifying Competency Print Name Certification/License Number <br /> 4. Breathing emergencies Affiliation Date <br /> Signature of Person Verifying Competency Print Name Certification/License Number <br /> 5.Automated external defibrillation Affiliation Date <br /> Signature of Person Verifying Competency Print Name Certification/License Number <br /> 6. Circulation emergencies Affiliation Date <br /> Signature of Person Verifying Competency Print Name Certification/License Number <br /> 7. Neurological emergencies Affiliation Date <br /> Signature of Person Verifying Competency Print Name Certification/License Number <br /> 8.Soft tissue injury Affiliation Date <br /> Signature of Person Verifying Competency Print Name Certification/License Number <br /> 9. Musculoskeletal injury Affiliation Date <br /> Signature of Person Verifying Competency Print Name Certification/License Number <br /> 10.Obstetrical emergencies Affiliation Date <br /> Signature of Person Verifying Competency Print Name Certification/License Number <br />