Certificate of Post-Graduate Medical Education form - Nebraska ... - dhhs ne 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the applicant's name and Social Security Number in the designated fields at the top of the form.
3. The Program Director must complete the certification section, including the applicant's name, residency/internship/fellowship details, and the institution's name, city, state, and country.
4. Fill in the dates of attendance by selecting the appropriate month, day, and year for both start and end dates.
5. Indicate whether the program was accredited by checking the relevant box for ACGME, AOA, RCPSC, CFPC, or if it was not accredited.
6. Answer questions regarding any disciplinary action or derogatory information by checking 'Yes' or 'No' and providing details if applicable.
7. Ensure that the Program Director signs the form. An official signature is required; a signature stamp is not acceptable.
8. Affix the institutional seal where indicated. If there is no seal, ensure that a notarization is completed instead.

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