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Attestation Form: Skin Assessments for Diverse Skin Tones by Medline
Today's Date
(Required)
MM slash DD slash YYYY
First Name
(Required)
Last Name
(Required)
Facility Name
(Required)
Email
(Required)
Number of CEU Credit Hours
(Required)
Up to 1
CEU's Requested
(Required)
BELTCA
NSBN
BELTCA Administrator ID Number (if applies)
(Required)
NSBN License Number (if applies)
(Required)
Attestation Statement
(Required)
Yes
By selecting 'Yes' above, you hereby attest that all information entered above is accurate as related to the number of hours attended during this training event.
Survey on Skin Assessment for Diverse Skin Tones
Please evaluate the Agenda and Speaker below:
Evaluate the Overall Agenda and Timing
(Required)
Excellent
Very Good
Good
Fair
Poor
Evaluate the Speakers
(Required)
Excellent
Very Good
Good
Fair
Poor
Additional Feedback
Please select Topics you would like to see in the next training
Choose as many topics
(Required)
Medication Management and Administration
Disease Management
Mental and Behavioral Health
Compliance Programs
Employee Satisfaction, Engagement, and Retention
Federal Codes and Legislation
Facility Management and Environmental Services
Quality Assurance and Performance Improvement
Regulatory Survey and Inspection Process
Other
list below:
Additional Feedback - Other topics
Δ
