Follow the steps to fill out the verification form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing the Employment History section. You will need to provide the hospital name, address, and the years of employment in the NICU or SCN. If you require more space, attach an additional page with this information.
3. Indicate the nursery level where you worked, selecting from levels II, III, or IV.
4. Specify your employment status by marking either Full Time (FT) or Part Time (PT) for your role.
5. In the next section, print your name and confirm your profession—choosing from Occupational Therapist, Physical Therapist, Speech Language Pathologist, or Registered Nurse. You will also need to sign and date this section.
6. Your supervisor or coworker must complete the verification of your clinical practice hours. They should print their name, title or credentials, sign, and provide their email address and date.
7. After completing all sections, review the form for accuracy. You can then save changes, download, print, or share the completed form as needed.

Complete your OH NTMC Verification Form For Clinical Practice Hours online today!