Certification_Statement_-_FY18.pdf

are prescribed in 18 U.S.C. 1001.

Print Name of Provider

1. I currently [ ] meet [ ] do not meet the experience required by PWS #GIMC-18-001, paragraph 6.1 - Experience.

If the experience requirement is met, attach a summary detailing employment history and job duties for the last 24 months.

2. License to practice [ ] has [ ] has not been restricted, terminated, suspended, or revoked.

If your license has been restricted, terminated, suspended, or revoked, provide a copy of the State Board of Physician document pertaining to each occurrence.

3. I currently hold the following active, unrestricted medical license as required by PWS #GIMC-18-001, paragraph 6.2 - License

(list all license):

4. I currently hold the following inactive medical license (list all license):

5. I have taken [ ] have not taken [ ] the Emergency Medicine Boards. If not taken, I meet [ ] not meet [ ] eligibility.

6. I currently hold the following certifications as identified by the PWS #GIMC-18-001, paragraph 6.3 - Certifications

Certification Expiration Certification Expiration Certification Expiration

BLS ATLS Cert. Wound Care

ACLS Fetal Monitoring

PALS BCLS

7. I meet the requirements of the PWS #GIMC-18-001, paragraph 6.4.1 - Medical Evaluation.

My most recent medical evaluation was completed on:

8. I meet the requirements of the PWS #GIMC-18-001, paragraph 6.4.2 - Immunization.

The dates of my immunizations are as follows:

Date Immunizations Completed:

Date Date

a. Immunity to Rubella, Mumps, Measles MMR#1 MMR#2

b. Immunity to Hepatitis B HEP B#1 HEP B#2

HEP B#3 declination

c. History of chicken pox (varicella) disease or positive titer positive titer disease

d. Tdap vaccine (Tdap) within the last 5 years Tdap

e. Documentation of receiving a TB Mantoux skin test PPD chest x-ray within the past 12 months or chest x-ray

f. Date of Influenza Vaccine:

9. I currently [ ] meet [ ] do not meet the language requirements of the PWS #GIMC-18-001, paragraph 6.5 - Language

Requirements and Cultural Awareness initial

10. I currently [ ] meet [ ] do not meet the information technology skill requirements required by PWS #GIMC-18-001, paragraph 6.6 - Information Technology Skills initial

11. I am aware of the orientation requirements of the PWS #GIMC-18-001, paragraph 6.7 - Orientation initial

12. I am aware of the background check required by PWS #GIMC-18-001, paragraph 6.8 - Background Checks initial

13. I am aware of the Work Schedule requirements of the PWS #GIMC-18-001, paragraph 5.2 - Work Schedule initial

State License No. Expiration Date

DateLegal Signature of Provider

Certification Statement for Performance Work Statement (PWS) No. GIMC-18-001

Emergency Room Physician Services

State License No. Expiration Date

I hereby certify the below statements are full, accurate, and complete. The penalties for making false statements

Recommended

(must be current) Date

Date

Mandatory Mandatory