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] |
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Department: | |
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Email Address: | |
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Phone Number: | |
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Equipment Details
Model: | Lift Assist Pro 3000 |
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Serial Number: | |
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Type of Equipment: | |
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Certification Details
Certification Date: | [Month Day, Year] |
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Supervisor Name: | |
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Validity Period: | |
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Assessment
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: | |
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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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