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EMT Skills Verification Form


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.

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

Contact Us

Coastal Valleys EMS Agency
195 Concourse Blvd., Suite B
Santa Rosa, CA 95403
(707) 565-6501
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