Common use of Attestation Form Clause in Contracts

Attestation Form. All students who are not included on the student list must fill out this Attestation Form stating they are a Training Partnership Student. Class and Module Number: Instructor Full Name: Student Last 4 SSN: Employer: Student Phone: (Include area code) If my instructor says there is room in the class, I may choose to stay but understand that I may not receive credit and/or may not be paid for my time. Student Name: Student Signature: An Incident is an unusual event that occurs surrounding instruction delivery and disrupts the class delivery process. Reported incidents should clearly outline all details relevant to the incident, the events contributing to the incident, the actions taken by the network provider in response to the incident, and if the incident was resolved or if additional actions are required. A Complaint is a statement that a situation is unsatisfactory or unacceptable. Learners with complaints should be encouraged to contact the MRC via phone at l-866-371-3200 or via email at ▇▇▇@▇▇▇▇▇▇▇.▇▇▇. Instructors with complaints should submit an Incident Report to the network PPC to escalate the issue to the Training Partnership. Incident Reporting Form The SEIU Healthcare NW Training Partnership is committed to ensuring that students, faculty, administrators, and staff spend their days in a safe and healthy environment. Together, we will make every effort to protect your identity and the confidentiality of this statement. However, we may need to contact you for further information as we investigate the incident. We are asking everyone to use this confidential form to report any concerns, incidents or potential incidents relating to: Personal Injury/sickness Disruptive /Inappropriate behavior Violence Disparagement of religion(s) or (including harm to self or others) engagement of religious activities Engagement of lobbying or Sexual harassment Other Are you: (circle one) Staff Instructor Student Student’s Employee: Date of Incident: Time of Incident: Place of Incident: (classroom, other) Person(s) directly involved in incident: Witness to Incident: Description Of Incident (Please provide specific details below and if necessary you may attach another sheet): Email: Phone: I acknowledge that I have read and understand the above statements. I certify that all statements made on this form are true and complete. I authorize the Training Partnership to disclose the information I provide as necessary in pursuing the investigation. Please submit this form to ▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ For Training Partnership Use Only: Action(s) taken in response to report: This policy is subject to change SEIU 775 Benefits Group (Benefits Group) is committed to the safety and personal health of both our students and instructors. We understand that there are circumstances that could affect an instructor’s capability to safely and effectively deliver the curriculum; examples include inclement weather, instructor illness, power outages, or fire. In these and similar circumstances, the following policies and procedures should apply.

Attestation Form. All students who are not included on the student list must fill out this Attestation Form stating they are a Training Partnership Student. Class and Module Number: Instructor Full Name: Student Last 4 SSN: Employer: Student Phone: (Include area code) If my instructor says there is room in the class, I may choose to stay but understand that I may not receive credit and/or may not be paid for my time. Student Name: Student Signature: An Incident is an unusual event that occurs surrounding instruction delivery and disrupts the class delivery process. Reported incidents should clearly outline all details relevant to the incident, the events contributing to the incident, the actions taken by the network provider in response to the incident, and if the incident was resolved or if additional actions are required. A Complaint is a statement that a situation is unsatisfactory or unacceptable. Learners with complaints should be encouraged to contact the MRC via phone at l-866-371-3200 or via email at ▇▇▇@▇▇▇▇▇▇▇.▇▇▇. Instructors with complaints should submit an Incident Report to the network PPC to escalate the issue to the Training Partnership. Incident Reporting Form The SEIU Healthcare NW Training Partnership is committed to ensuring that students, faculty, administrators, and staff spend their days in a safe and healthy environment. Together, we will make every effort to protect your you r identity and the confidentiality of this statement. However, we may need to contact you for further information as we investigate the incident. We are asking everyone to use this confidential form to report any concerns, incidents or potential incidents relating to: Personal Injury/sickness Disruptive /Inappropriate behavior Violence Disparagement of religion(s) or (including harm to self or others) engagement of religious activities Engagement of lobbying Bullying political activity drugs, or weapons Sexual harassment Other Are you: (circle one) Staff Instructor Student Student’s Employee: Date of Incident: Time of Incident: Place of Incident: (classroom, other) Person(s) directly involved in incident: Witness to Incident: Description Of Incident (Please provide specific details below and if necessary you may attach another sheet): Email: Phone: I acknowledge that I have read and understand the above statements. I certify that all statements made on this form are true and complete. I authorize the Training Partnership to disclose the information I provide as necessary in pursuing the investigation. Please submit this form to ▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ For Training Partnership Use Only: Action(s) taken in response to report: This policy is subject to change SEIU 775 Benefits Group (Benefits Group) is committed to the safety and personal health of both our students and instructors. We understand that there are circumstances that could affect an instructor’s capability to safely and effectively deliver the curriculum; examples include inclement weather, instructor illness, power outages, or fire. In these and similar circumstances, the following policies and procedures should apply.