Nursing Home Equipment Operation Certification Form

Date: [Month Day, Year]

Please read through each section carefully and fill in all required information accurately. Upon completion, this form should be signed by the instructor/supervisor and the employee.

Employee Information

Full Name:	[Name]
Department:
Email Address:
Phone Number:

Equipment Details

Model:	Lift Assist Pro 3000
Serial Number:
Type of Equipment:

Certification Details

Certification Date:	[Month Day, Year]
Supervisor Name:
Validity Period:

Assessment

Date:	[Month Day, Year]
Theory Test Score:
Practical Test Score:
Observations:
Certification Status:

Supervisor Signature:

[Your Name]

[Job Title]

[Month Day, Year]

Employee Acknowledgment

I acknowledge that I have been trained and tested on the operation of the equipment listed above and understand the safety protocols and operational procedures. I understand that my certification is subject to periodic review and can be revoked if I fail to adhere to the established safety standards and operational guidelines.

Employee Signature:

[Name]

[Job Title]

[Month Day, Year]

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