Application for Certification Documentation and Fee - Public Health - public health oregon 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Applicant Information section. Clearly print your name, address, telephone number, and email. Ensure all details are accurate.
3. Indicate your certification type by checking either 'Full Certification' or 'Provisional Certification'. If applicable, select 'Initial', 'Renewal', or 'Name/Address Change'.
4. Complete the Hemodialysis Employers section by listing your employers in reverse chronological order. Include facility names, locations, and dates of employment.
5. For Initial Certifications only, provide documentation of Hemodialysis training received. Attach any necessary additional pages.
6. Answer all questions in the Questions section honestly. If you answer 'Yes' to any question, provide a detailed explanation on an attached page.
7. For Certification Renewals, list the hours worked during the current certification period and ensure manager signatures are included where required.
8. Review your application for completeness before submitting it via mail to the specified address. Ensure all required signatures are present.

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