Nursing Home Equipment Operation Certification Form
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
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Full Name: |
[Name] |
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Department: |
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Email Address: |
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Phone Number: |
Equipment Details
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Model: |
Lift Assist Pro 3000 |
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Serial Number: |
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Type of Equipment: |
Certification Details
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Certification Date: |
[Month Day, Year] |
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Supervisor Name: |
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Validity Period: |
Assessment
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Date: |
[Month Day, Year] |
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Theory Test Score: |
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Practical Test Score: |
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Observations: |
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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]
