NIHT Clinical Skills Checklist & Hour Verification Form

NIHT Clinical Skills Checklist & Hour Verification Form

(Completed by Clinical Supervisor and returned to NIHT)
This form is used to verify completion of the 20 required clinical practice hours for the
Sleep Technology Essentials – 80-Hour Certificate Program.

This form must be completed and signed by the clinical supervisor/preceptor and submitted to the National Institute for Health Technology (NIHT) upon completion of clinical hours.

Incomplete or unsigned forms will not be accepted.
SECTION 1: STUDENT INFORMATION
Student Name

First NameLast Name
Student Email Address
example@example.com
Cohort:

SECTION 6: SUPERVISOR ATTESTATION
Supervisor Attestation Statement

I attest that the above-named student has completed 20 supervised clinical practice hours and has demonstrated competency in the skills indicated above to the best of my knowledge.

SECTION 1: STUDENT INFORMATION