CLINICAL SKILLS CHECKLIST VERIFICATION FORM

Please use this form to document your clinical skills have been completed.

This electronic form allows you to document your completed clinical skills:

Enter your candidate information at the top (it will auto-populate for all skill sets)
Complete all required fields (marked with *) and check off each completed clinical skill
Use the "Add Clinical Skills" button to add multiple skill sets (one for each supervisor)
When complete, use the "Download PDF" or "Print Form" button
For each printed/downloaded form, obtain your clinical supervisor's signature
Sign the attestation section on each printed form
Combine all signed forms into a single file and upload to your online application

NOTE: Signatures can only be added to the printed/downloaded version of this form, not the electronic version.

Full Name:

Email:

Candidate Name:
Candidate Email:
Facility where clinical skills completed:
Start Date:		\| End Date:
Supervisor Name:
Supervisor Telephone:
Supervisor's Credentials / Title:
Facility Address:
Facility City:
Facility State:
Facility Zip Code:
Facility Country:

CANDIDATE SECTION