Sliding Board Transfer Instruction Acknowledgement Form
Please confirm you have received and understood the sliding board transfer instruction. Complete all fields below to acknowledge your understanding.
Full Name
*
First Name
Last Name
Role / Relationship
*
Please Select
Patient
Caregiver
Family Member
Other
Date of Acknowledgement
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Staff Providing Instruction
*
How confident do you feel performing a sliding board transfer?
*
1
2
3
4
5
Were all your questions about the sliding board transfer answered?
*
Yes
No
Additional Comments or Questions
I acknowledge that the sliding board transfer instruction was explained to me and I understand how to safely perform a sliding board transfer.
*
I acknowledge and understand the instruction
Submit Acknowledgement
Should be Empty: