"Training Entity Emt-B Skills Verification Form" - Missouri

Training Entity Emt-B Skills Verification Form is a legal document that was released by the Missouri Department of Health and Senior Services - a government authority operating within Missouri.

Form Details:

  • Released on August 1, 2007;
  • The latest edition currently provided by the Missouri Department of Health and Senior Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Missouri Department of Health and Senior Services.

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
BUREAU OF EMERGENCY MEDICAL SERVICES
TRAINING ENTITY EMT-B SKILLS VERIFICATION
FOR DOH OFFICE USE ONLY-DO NOT WRITE IN THIS SPACE
TRAINING ENTITY ACCRED NO.
DATE FORM RECEIVED
DATE FORM RECEIVED
__________________________
____/____/____
____/____/ ____
APPLICANT MUST COMPLETE INFORMATION BELOW
TRADE NAME OF TRAINING ENTITY
DAYTIME TELEPHONE NO.
TRAINING ENTITY BUSINESS ADDRESS (STREET, ROUTE, CITY, STATE, ZIP)
2. PROGRAM DIRECTOR
NAME (LAST, FIRST, MI)
TELEPHONE NUMBER
MAILING ADDRESS (STREET, ROUTE, PO BOX, ETC)
FAX NUMBER
CITY
STATE
ZIP CODE
E-MAIL
3. STATEMENT OF COMPETENCY IN EMT-BASIC SKILLS
As the EMT-Basic Training Program Director, I verify that the students listed have been examined and performed
satisfactorily so as to be deemed competent in each of the following skills:
Patient Assessment/Management - Trauma
Mouth-to-Mask with Supplemental Oxygen
Patient Assessment/Management - Medical
Spinal Immobilization Supine Patient
Cardiac Arrest Management/AED
Spinal Immobilization Seated Patient
Bleeding Control/Shock Management
Long Bone Immobilization
Bag-Valve-Mask Apneic Patient
Joint Dislocation Immobilization
Supplemental Oxygen Administration
Traction Splinting
Upper Airway Adjuncts and Suction
Basic Ventilatory Management EOA or Dual Lumen
I HEREBY CERTIFY that this application contains no misrepresentation or falsifications and that the information
given by me is true and complete to the best of my knowledge. I further certify that the above named training entity
has both the intention and the ability to comply with the regulations promulgated under the Comprehensive EMS Act,
Chapter 190, RSMo 2000.
SIGNATURE OF PROGRAM DIRECTOR
DATE
WARNING: In addition to licensure action, anyone who knowingly makes a false statement in writing with the intent to
mislead a public servant in the performance of his official duty may be guilty of a class B misdemeanor. Missouri Statutes
575.060
Mail form to: Bureau of Emergency Medical Services, P.O. Box 570, Jefferson City, MO 65102
(R 08/07)
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
BUREAU OF EMERGENCY MEDICAL SERVICES
TRAINING ENTITY EMT-B SKILLS VERIFICATION
FOR DOH OFFICE USE ONLY-DO NOT WRITE IN THIS SPACE
TRAINING ENTITY ACCRED NO.
DATE FORM RECEIVED
DATE FORM RECEIVED
__________________________
____/____/____
____/____/ ____
APPLICANT MUST COMPLETE INFORMATION BELOW
TRADE NAME OF TRAINING ENTITY
DAYTIME TELEPHONE NO.
TRAINING ENTITY BUSINESS ADDRESS (STREET, ROUTE, CITY, STATE, ZIP)
2. PROGRAM DIRECTOR
NAME (LAST, FIRST, MI)
TELEPHONE NUMBER
MAILING ADDRESS (STREET, ROUTE, PO BOX, ETC)
FAX NUMBER
CITY
STATE
ZIP CODE
E-MAIL
3. STATEMENT OF COMPETENCY IN EMT-BASIC SKILLS
As the EMT-Basic Training Program Director, I verify that the students listed have been examined and performed
satisfactorily so as to be deemed competent in each of the following skills:
Patient Assessment/Management - Trauma
Mouth-to-Mask with Supplemental Oxygen
Patient Assessment/Management - Medical
Spinal Immobilization Supine Patient
Cardiac Arrest Management/AED
Spinal Immobilization Seated Patient
Bleeding Control/Shock Management
Long Bone Immobilization
Bag-Valve-Mask Apneic Patient
Joint Dislocation Immobilization
Supplemental Oxygen Administration
Traction Splinting
Upper Airway Adjuncts and Suction
Basic Ventilatory Management EOA or Dual Lumen
I HEREBY CERTIFY that this application contains no misrepresentation or falsifications and that the information
given by me is true and complete to the best of my knowledge. I further certify that the above named training entity
has both the intention and the ability to comply with the regulations promulgated under the Comprehensive EMS Act,
Chapter 190, RSMo 2000.
SIGNATURE OF PROGRAM DIRECTOR
DATE
WARNING: In addition to licensure action, anyone who knowingly makes a false statement in writing with the intent to
mislead a public servant in the performance of his official duty may be guilty of a class B misdemeanor. Missouri Statutes
575.060
Mail form to: Bureau of Emergency Medical Services, P.O. Box 570, Jefferson City, MO 65102
(R 08/07)
STUDENT NAME MUST BE TYPEWRITTEN ALPHABETICALLY
List student’s last name first
Last Name:
First Name:
Last Name:
First Name:
SIGNATURE OF PROGRAM DIRECTOR
DATE
(R 08/07)
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