Form 1IC Office of the Professions Attestation of ...

5 form 1IC The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professions Division of Professional Licensing Services Registration/Fee Unit 89 Washington Avenue Albany, NY 12234-1000 Attestation OF INFECTION CONTROL TRAINING INSTRUCTIONS Complete Items 1-8 and return this form to the address printed above. Keep a photocopy of this completed and signed form with other pertinent documentation ( copy of any course completion certificate) in your personal files. 1 2 SOCIAL SECURITY BIRTH DATE NUMBER (Leave this blank if you do not have a Social Security Number) mo.

Office of the Professions Division of Professional Licensing Services www.op.nysed.gov Form 1IC Attestation of Infection Control Training Instructions. Complete items 1-7. Be sure to sign and date item 8. Submit the completed form along with any other required documentation (i.e. copy of …

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