Verification of Calls and Skills
Agency Name ______________________________________________________________________________
Chief Officer _______________________________________________________________________________
Phone number for Chief Officer/Supervisor _________________________________________________________
I hereby attest that ___________________________________________ is a member/employee of
(Applicant name)
___________________________________________________________ since _____________________.
(Name of organization) (date)
She/he has been certified as an EMT actively riding with this agency for ________ or ________ and has
completed more than 50 emergency calls.
She/he has been observed within this agency performing the following skills or actions and is capable of functioning
as an entry level EMT.
Patient assessment including vital signs
Patient lifting and moving
CPR
Hypoperfusion interventions
Airway management/Oxygen administration Immobilization/dressing/bandaging Medication assist
Verbal and written reporting including use of radios
I am unaware of any criminal or disciplinary actions pending against this applicant.
I am aware that this verification is part of an application to the Hudson Valley Paramedic Program.
Signature of Chief Officer/Supervisor _____________________________________________________________
Print name of Chief Officer/Supervisor ____________________________________________________________
Date __________________________
Medical Director’s Statement
I am aware of this Verification of Calls and Skills request made as part of the application process to the Hudson Valley
Paramedic Program. I feel this individual is competent to participate as a student and EMT in advanced level training
at this time.
Medical Director’s Name ______________________________________________________________________
(Please print name)
Medical Director’s Signature ___________________________________________________________________
Date ______________________________
PAGE 2
(years) (months)
