Free Nursing Home Patient Affidavit Template
Nursing Home Patient Affidavit
STATE OF
COUNTY OF
I, [Your Name], of legal age, currently residing at [Your Company Address], employed as [Your Position] at [Your Company Name], hereby swear and affirm under oath and penalty of perjury, the following statements are true and correct to the best of my knowledge and belief:
1. Background and Qualification
a. I am employed as [Your Position] at [Your Company Name], with a business address of [Your Company Address]. In this capacity, I have been working in the nursing home industry for [Number of Years] years.
b. I possess extensive experience and training relevant to nursing home operations, elderly care standards, and regulatory compliance within the state of [State].
c. My qualifications include a Bachelor of Science in Nursing (BSN) and a Certified Nursing Home Administrator (CNHA) license, which support my familiarity with industry standards and best practices in elderly care.
2. Statement of Facts
a. This affidavit is executed in relation to the case between [Plaintiff’s Name] and [Defendant’s Name], currently pending before the [Court Name/Location].
b. I have direct knowledge of the policies, standards, and practices that govern care for elderly residents in nursing facilities, specifically relating to the matter at issue.
c. I have reviewed documents, records, and other materials that evidence the quality and level of care provided to the resident in question, [Resident's Name], during their stay at [Facility Name].
3. Observations and Findings
a. Based on my professional experience and review of the pertinent documentation, I have formed opinions regarding the adequacy of care and adherence to regulatory standards by [Facility Name or Defendant’s Name] concerning the resident [Resident's Name].
b. Specific observations include regular adherence to medication schedules, timely response to health concerns, and appropriate staff-to-resident ratios during [Resident's Name]'s residency.
4. Sworn Oath
a. I hereby affirm that the statements made herein are true and accurate to the best of my knowledge, understanding, and belief.
b. I understand the legal implications of submitting false statements within this affidavit and am aware of my responsibilities under the law.
5. Conclusion
a. Based on the foregoing, I submit this affidavit to aid in the resolution of the legal matter between [Plaintiff’s Name] and [Defendant’s Name].
b. There are no omitted facts known to me that would materially affect the outcome of the ongoing case.
6. Execution
In witness whereof, I have hereunto set my hand and affixed my seal at [Your Company Address], on this day of , 20.
Signature:
[Your Name]
[Your Position]
[Date]
Subscribed and sworn to (or affirmed) before me on this day of , 20, by [Your Name], who is personally known to me or has produced as identification.
Notary Public Signature:
Print Name:
My commission expires:
Seal:
