EMS Course Completion Verification Form
|Certification Code: |Send completed document to: |Special Skills Code: |
|Enter the appropriate number code | |Enter the appropriate number code |
|1 = Emergency Medical Responder |EMS Education and Training |1 = IV Monitor/Maintenance |
|2 = EMT (Includes RN to EMT) |P.O .Box 47853 |2 = Intravenous Therapy |
|3 = Advanced EMT |Olympia, WA 98504-7853 |3 = Manual Defibrillation |
|4 = Paramedic | |4 = Supraglottic Airway |
| |Phone: 360-236-2840 | |
|Training Program: | |Course Location: |
|Course Approval Credential Number: | |Completion Date: |
| |Approval Signatures: |
|Training Program Director: _________________________________________ |Senior EMS/*Lead Instructor: _______________________________________ |
|Delegated Training Physician: _______________________________________ |County Medical Program Director: ___________________________________ |
|We hereby attest that those individual(s) listed below ho have successfully completed the course have met the course requirements as defined in RCW 18.7 or 18.73. |
|* EMR and EMT courses require a DOH approved SEI. For other course instructor qualification requirements, see the EMS Education Standards Manual |
| |Last Name |First Name |M.I. |To document special skill endorsement, enter EMT credential|Clinical/Field Completion |Clinical/Field |Course Completion |
| | | | |number if available. |Date: |Verified By: |Pass or Fail |
| | | | |(IV Therapy or Supraglottic Airway Training only) | | | |
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Last NameFirst NameM.I.Add SSN or WA EMS Credential Number to document special skill endorsement. (IV Therapy or Supraglottic Airway Training only)Clinical/Field Completion Date:Clinical/Field
Verified By:Course Completion
Pass or Fail11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
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DOH 530-008 November 2011
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