Flu Vaccination Competency Declaration Form
Please complete this form to declare your competency in flu vaccination procedures. All information should be accurate and up-to-date.
Full Name
*
First Name
Last Name
Role or Job Title
*
Organization or Site
*
Contact Email
*
example@example.com
Declaration of Competency and Training Status
*
I have completed all required training for flu vaccination procedures.
I am currently undergoing training for flu vaccination procedures.
I have not yet started training for flu vaccination procedures.
Date of Last Flu Vaccination Training or Competency Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Method of Competency Verification
*
Please Select
Direct observation
Written assessment
Practical demonstration
Other
Supervisor or Verifier Name
*
Declaration of Understanding and Accuracy
*
I confirm that the information provided is accurate and that I understand the requirements for flu vaccination competency.
Signature
*
Date of Declaration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Declaration
Submit Declaration
Should be Empty: