National Registry of Emergency Medical Technicians

Emergency Medical Technician Psychomotor Examination

Verification Form

Candidate Information	

Name	
 	  Application Confirmation Number    			

Address   		

City	
State		
Zip		
–	

Phone   		
Email					

To Be Completed by the Instructor, Training Officer or EMS Service Director:

I verify that	 	  (candidate name) has completed a state-approved psychomotor examination equal to or exceeding the criteria established by the NREMT and preformed satisfactorily so as to be deemed competent in the following skills:

•	Patient Assessment/Management – Trauma
•	Patient Assessment/Management – Medical
•	BVM Ventilation (Apneic Adult Patient)
•	Oxygen Administration by Non-rebreather Mask
•	Cardiac Arrest Management/AED
•	Spinal Immobilization (Supine Patient)
•	Random Skill Verification
o Spinal Immobilization (Seated Patient) o Bleeding Control/Shock Management o Long Bone Immobilization
o Joint Immobilization

Psychomotor Exam Location	Exam Date

Name of person verifying psychomotor examination	Title

Signature	Date

I hereby affirm that all statements on the EMT Psychomotor Examination Verification are true and correct. It is understood t hat false statements may be sufficient cause for revocation and other appropriate actions by the NREMT. It is also understood that NREMT may conduct an audit of the skills listed at any time.

Candidate Signature	Date

© 2011 by the National Registry of Emergency Medical Technicians, Inc., Columbus, OH	e10-12
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