Emergency Medical Technician (EMT) Certification Form

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A standardized form used to verify an individual's EMT certification and training, typically issued by a state or national certifying agency.

Implementing an EMT Certification form can benefit your organization in several ways. It ensures that all employees holding EMT certifications are properly documented and tracked, reducing administrative burdens on HR departments. The form helps to verify the authenticity of certification credentials, preventing potential fraud or misrepresentation. Moreover, it facilitates the efficient management of employee skills and qualifications, making it easier to assess training needs and develop targeted professional development programs.

Personal Information:

• Name
• Date of Birth
• Address
• Contact Information

Education and Training:

• Completion of an EMT-Basic training program
• Documentation of hours spent on clinical rotations and field internships

Certification and Licensure:

• Current certification in Cardiopulmonary Resuscitation (CPR)
• Proof of state licensure or certification as an EMT-Basic

Emergency Medical Technician Certification:

• Number of hours completed for the EMT-Basic training program
• Date of completion of the EMT-Basic course
• Number of field internships and clinical rotations completed
• Number of continuing education hours completed within the past 24 months

Professional Information:

• Employer information (if currently employed as an EMT)
• Supervisor's signature and contact information

Certification Application Fee

Signature Block: