Free Long Term Care Facility Feeding Assistant Roster-F-62595 - Wisconsin


File Size: 11.1 kB
Pages: 1
Date: November 21, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: Division of Quality Assurance
Word Count: 55 Words, 351 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f6/f62595.pdf

Download Long Term Care Facility Feeding Assistant Roster-F-62595 ( 11.1 kB)


Preview Long Term Care Facility Feeding Assistant Roster-F-62595
DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62595 (Rev. 11/08)

STATE OF WISCONSIN

LONG TERM CARE FACILITY FEEDING ASSISTANT ROSTER
CFR 483.16(b) requires a facility to maintain a record of all feeding assistants used by the facility. Name - Facility License Number

NAME OF FEEDING ASSISTANT

SOCIAL SECURITY NUMBER

DATE OF HIRE