Please use this form when taking an annual skills review outside a WPAHS facility.  Please note that Dr. Conti will NOT accept all skills reviews.  It is best to check with Gary prior to taking a skills review at an outside facility.

 

Paramedic's Last Name ________________________   First Name ________________   M.I.  _____

Paramedic Certification # ______________________   Service Affiliate _______________________

INFORMATION BELOW TO BE COMPLETED BY EMS MEDICAL DIRECTOR AT VERIFYING FACILITY

 

Dear Dr. Conti:

Please be advised that Paramedic ____________________________  has successfully completed an annual ALS Skills Review held at ______________________________  on __________________ ___, 2002.  I have checked the appropriate boxes below as to those skills reviewed during the session.  If you have any questions concerning this individual please contact me at _____.____._____.

___ BCLS (CPR) ___ Adult Intubation
___ Infant Intubation ___ Intraosseous Infusion
___ Intravenous Infusions ___ Chest Decompression
___ Cricothyroid Membrane Puncture ___ EKG Interpretation
___ Defibrillation ___ Pacing
___ Cardioversion ___ Combi-Tube
___ Other (Please List)

 

 

A written exam was/was not (circle) given.  The above noted individual had a percentage score of ____.

 

Sincerely,

 

EMS Medical Director