Overview 

A completed EMT Skills Verification Form (EMSA-SCV 01/17) is required for those individuals who are either renewing or reinstating their EMT certification. The verification form must accompany the application when submitted. 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. 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.

Please ensure the form is correctly completed in accordance with the following instructions. These instructions are repeated on page 2 of the Skills Verification Form for reference.

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:

• Sign the EMT Skills Competency Verification Form for that skill.
• Print their name on the EMT Skills Competency Verification Form for that skill.
• Provide the name of the organization that has approved them to verify skills.
• Provide their certification or license type and number.

Approved Skills Verifier Requirements

In order to be an approved skills verifier you must meet the following qualifications:

Be currently licensed or certified as an EMT, AEMT, Paramedic, Registered Nurse, Physician Assistant, or Physician, and have authorization to verify EMT skills from:

• 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 provider, and other EMS providers

Explanation of Box 9: Naloxone/Epinephrine Administration

Effective July 1 2017 the skills verification form was updated to reflect changes to California Code of Regulations (CCR) Title 22 EMT regulations governing EMT scope of practice allowing Local EMS Agencies to incorporate Naloxone and Epinephrine into EMS system protocols for EMTs functioning as part of the organized EMS System.

The CCR Title 22 regulations mandate all EMTs renewing certification after July 1, 2019 present proof of competency to their certifying Local  EMS Agency with renewal application.

CVEMSA EMS System providers completing LEMSA-Approved training and competency testing prior to July 1, 2019 may have the Skills Verification Form signed by the trainer as a verification of competency.

Download Form

• Skills Verification Form EMSA-SCV 01/17 

Questions regarding this requirement may be directed to: This email address is being protected from spambots. You need JavaScript enabled to view it.

The California Health and Safety Code (HSC) requires individuals or organizations placing an Automatic External Defibrillator (AED) to notify the local EMS Agency of the location and type of AED placed.

HSC 1797.196 (b) (1) “… a person or entity that acquires an AED shall do the following:”

“… (B) Notify an agent of the local EMS agency of the existence, location, and type of AED acquired…”

Click here to view the HSC section referenced above.

Coastal Valleys EMS Agency (CVEMSA) is the Local EMS Agency (LEMSA) for Sonoma and Mendocino Counties. CVEMSA uses the PulsePoint AED Registry for capturing the information required by California Health and Safety Code, and uses that system to assist the local EMS responders in maintaining an awareness of AEDs in the community, as well as alerting bystanders for those AEDs that are publicly available.

To complete the notification process please enter AED information directly into the PulsePoint AED registry here:

PulsePoint AED Registry

Please note, the information entered is for the purpose of public safety response awareness, emergency alerting and regulatory notification. When registering, AED owners may choose to allow their AEDs to be visible and available to the general public for use in emergency situations, or restrict access to designated staff. AED owners may choose to provide PulsePoint with detailed information regarding their AED placement hovever the only required information that needs to be provided for the purpose of compliance with Health and Safety Code is the location and type of AED placed. 

PulsePoint is a national registry of AEDs and CVEMSA utilizes the system to resister AEDs within the LEMSA juristiction. PulsePoint does not sell customer data, and publishes privacy practices here:

• https://www.pulsepoint.org/registryterms
• https://www.pulsepoint.org/eula
• https://www.pulsepoint.org/foundation#privacy

AED owners with questions may This email address is being protected from spambots. You need JavaScript enabled to view it.or contact us via phone at (707) 565-6501

The PulsePoint AED registry and PulsePoint AED system are provided through a partnership with Save Lives Sonoma and Save Lives Mendocino (Citizens for Public Resuscitation, a 501c3 educational organization) and supported by grant funding from the PulsePoint Foundation.

Common Certification/Accreditation Forms. Please note the website certification and accreditation pages contain addtional information applicants should review to ensure a smooth credentialing experience.

Note on Application Documents: To ensure efficient, accountable processing, CVEMSA utilizes an online License Management System for all EMT and paramedic applications. There is no paper-based application process available. Applicants without computer access may contact EMS Agency staff to arrange an appointment to apply at the EMS Agency office using a staff computer. Appointments are subject to staff availability and must be pre-scheduled to ensure appropriate staff are present to provide support. CVEMSA does not have the ability to support drop-in unannounced counter service, but will arrange for staff to be available to assist if an appointment is requested. 

Forms:
 Live Scan form  For new EMT applicants or reinstatement applicants with a certificate lapse over one year only. Renewal applicants with a Live Scan on file do not need to complete this form or repeat the Live Scan process.

Live Scan locations Locations to bring the form for the Live Scan fingerprint process. 

EMT Certification of Individuals with Criminal Conviction History Important information for applicants with any conviction history. Applicants with a criminal background are encouraged to speak with Agency staff and/or legal counsel prior to applying for a Health Care license such as an EMT Certificate or local accreditation for paramedic license.

Skills Competency Verification Form Required for for EMTs renewing certification or reinstating lapsed certification. NOTE: This form is only valid if completed by an EMT, Paramedic or higher level license holder expressly authorized by an EMS provider agency, EMT or Paramedic Training Program or EMS Continuing Education Provider.  

Field Orientation Sign-off Form Paramedic Accreditation Orientation Sign Off. Used to document the completion of orientation to provider agency, Base Hospital orientation, Communications Center orientation and field training orientation. Required for initial Paramedic Accreditation applicants

ALS Accreditation Field Evaluation Form Evaluation form documenting five ALS clinical contacts observed by a CVEMSA approved Preceptor/Evaluator. Required for initial Paramedic Applicants

Flight Paramedic Area Orientation Form  Used to document completion of area orientation process by EMS Aircraft provider agency. Required for completion of inital Flight Paramedic Accreditation process.

Please contact EMS Agency staff with any questions or concerns regarding the forms or credentialing process or to arrange an appointment at (707) 565-6501 or via email at: This email address is being protected from spambots. You need JavaScript enabled to view it.

Save Lives Sonoma is an organized program structured to offer CPR, AED and first aid training for professional businesses and local organizations, to provide training to those in the community who have a duty to respond to a first aid or cardiac emergency because of job responsibilities or regulatory requirements. We also provide CPR training to friends and families of children or adults at risk of injury or heart disease.

Save Lives Sonoma’s mission is to get 100 percent of Sonoma County residents trained in hands-only CPR, and to increase awareness of the importance of bystander CPR.

Visit SaveLivesSonoma.com