Please read the following attestation and complete the electronic signature form below. 

I, the undersigned, certify on behalf of myself or my organization/agency that I have reviewed and completed the Missed Visit and Critical Incident Reporting Training. 

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1. Name (Required.)

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2. Organization/agency name (Required.)

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3. Preferred method of contact (Required.)

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4. Additional training needs or follow-up contact by your Account Executive

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5. Tax identification number (TIN) (Required.)

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6. I confirm that I understand the missed shift reporting information and attest that missed shift reporting requirements are incorporated into the above named organization’s reporting process. (Required.)

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7. I confirm that I understand the EIM and Critical Incident information and attest that missed shift reporting requirements are incorporated into the above named organization’s reporting process. (Required.)

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8. Comments, questions or feedback

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9. By entering your electronic signature, you certify that your responses above are accurate, truthful and complete to the best of your knowledge. PLEASE ENTER YOUR FULL NAME BELOW. (Required.)

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10. DATE SIGNED (Required.)

Date
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