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Instructor and Student Fit Test Verification/Attestation Form
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Instructions
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Please complete one form per organization and send to:
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Austin: Nichole Bustos- Nichole.Bustos@hcahealthcare.com
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El Paso: Myriam Gandy - Myriam.Gandy@hcahealthcare.com
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This document is verification/attestation that the following listed instructor(s)/student(s) have completed the requirements set forth by St. David's Healthcare and Las Palmas Del Sol Healthcare
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Attestation Statement: I, ____ (Name)__ ___, on behalf of ____ (School Name)_____ attest that all of the students below have been fit tested and documentation of these results is stored at our university. Below is a summary of this data for you to review for the current clinical rotation request.
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Organization Name:Date:
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Email Address/Phone #:
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Program Discipline
Last NameFirst NameFacility
Fit Test Date
Fit Test Result (Pass/Fail)
Mask Size
Mask Brand/Model
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