Raven EMS Education Program Manual
Terminal EMT Competency Form

Student's name:

Program name:

Course start date:

Student completion date:

All of the following must be verified and documented prior to requesting a certificate of completion for the EMT or paramedic program. Enter the verification date for each of the following along with any appropriate comments. Supporting documentation should be attached to this document.

• Student has submitted all required paperwork.
• Minimum hour requirements for program/state have been met.
• Hours completed:
• Hours required:
• High stakes exam and term scores are above minimum required.

  High Stakes Exam Description	Score	Min Reqd Score
  	%	%
  	%	%
  	%	%
  	%	%

• Certifications have been successfully completed.

  Program	Certification	Date Completed	Expiration Date
  EMT	BLS
  	EVOS

• Overall program score is above minimum required.
• Overall score: %
• Minimum required: %
• Minimum skill competencies have been met. (Report attached).
• Minimum number of required patient contacts have been met. (Report attached).
• Capstone evaluations:
• Student successfully completed the capstone cognitive examination. (Report attached).
• Platinum timed comprehensive adaptive test, or cumulative summary results with “Good” in all categories.
• Student has successfully completed a Technical Scope of Practice (TSoP) EMT Evaluation Form. (Attached).
• A final Student Affective Behavior Evaluation Form has been completed. (Attached).
• Student evaluations:
• A Student Academic Advising and Counseling Form has been completed for each term. (Attached).
• A Clinical Student Field Internship Mentor Final Evaluation Form has been completed. (Attached).
• Student has completed an Instructor and Course Evaluation by Students Form.
• Student has completed a Program Resource Survey by Students Form.
• Administrative:
• Program materials (i.e. resource texts) and equipment has been returned.
• Student address/email/phone is updated in system.
• Student has been instructed on NREMT and/or state licensure process.
• Employment information added/updated in the system.
• Employer survey reminder scheduled for (12 months after completion).
• Graduate survey reminder scheduled for (12 months after completion).

We hereby attest that the candidate listed below successfully completed all of the terminal competencies required for graduation from EMT or paramedic program as a minimally competent, entry-level EMT or paramedic and as such is eligible for State and National Certification written and practical examination in accordance with our published policies and procedures.

Lead Instructor’s signature:
Clear

Program Director’s signature:
Clear

Medical Director’s signature:
Clear

	Relevant. Resolute. Ready.
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