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301, P.O. Box 997416 Sacramento, CA 95899-7416 PHONE: (916) 327-2445 FAX: (916) 324-0901 SAMPLE FORM (May be used by provider) NURSE ASSISTANT TRAINING PROGRAM SKILLS CHECK LIST Student Name Enroll Date *Social Security Number Training Program Completion Date Clinical Site Name Instructor s Name Title Initials Signature Clinical Date Hours Clinical Date Hours S Satisfactory NURSE ASSISTANT TRAINING PROGRAM SKILLS DEMONSTRATED MODULE 6: Hand washing 2) Proper handling of line.

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