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Get In State Form 49560 2018-2024

He penalties of perjury that the foregoing is true and accurate, and that I have read and understood 42 CFR 484.36 and have completed a competency evaluation program as required by this regulation. Home Health Aide s Signature Date (month, day, year) Registered Nurse s Name Conducting Competency Evaluation: I, , swear and affirm under the penalties of perjury that the foregoi.

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