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Get DESIGNATED AGENCY TO VERIFY AND COMPLETE - Keck Usc

ME OF SCHOOL/EMPLOYER (If applicable): PHONE NO.: * * IDENTIFICATION NO.: * WORK AREA/UNIT: SHIFT: CONTACT PERSON: * Completion of this certificate certifies the individual identified above has met the Los Angeles County Department of Health Services (DHS) Pre-placement OR Annual health clearance requirements in accordance with DHS policy. I. FOR COMPLETION BY THE PHYSICIAN OR LICENSED HEALTH CARE PROFESSIONAL (PLHCP) INSTRUCTIONS TO THE PLHCP: Please complete the following forms AND.

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