VALIDATION OF LPN ACUTE CARE EMPLOYMENT 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Employee Name in the designated field. Ensure accuracy as this is crucial for identification.
3. Fill in the Place of Employment and Company Address, including City, State, and Zip Code. This information verifies the employment location.
4. Indicate the Employee Unit and Start Date. This helps establish the employee's tenure at your facility.
5. Answer whether the person is still employed by selecting 'Yes' or 'No'. If 'No', provide the last date of employment.
6. Document the Total Hours of Employment and verify if they worked 24 hours per week for a minimum of six months.
7. Complete the Supervisor’s Name and Phone Number fields for contact purposes.
8. Finally, have the Supervisor sign and date the form to validate its authenticity.

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