ATTESTATION LETTER REQUEST

SLPMASTERS ON-CAMPUSPROGRAM
This form must be completed and submitted on time along with the required documents. All sections
must be completed, no exceptions. If the information does not pertain to you, please mark as N/A. If any
documentation is missing or sections are left blank, this form will not be processed. Please read all
instructions carefully. If you have any questions, please contact Dr. Bolinger via e-mail: cbolinger@twu.edu
. ALL DOCUMENTSMUST BE SUBMITTED VIA EMAIL AS ATTACHMENTS .

Section A – Student Information and Attestation Request

Date: 4/26/2022 Semester: Fall Spring Summer Year 2022

Student Name: Fred Arthur Fisher TWU ID #: 1307721
Does your site require an attestation letter? Yes No

If no, please go to Section B. This form must still be completed. Your site will still receive an
Attestation Letter along with a copy of your liability card and TWU Insurance

If yes, please list the Attestation Due Date (This is the date your attestation letter is due at your site):

Section B – Supervisor and Externship Information

Full Name and e-mail address of Person Attestation should be addressed to: PLEASE TYPE OR
PRINT CLEARLY YOUR SUPERVISOR’S INFORMATION.

Fred Fisher ffisher@twu.edu

First Name Last Name E-mail Address

Externship Site (Complete name): Angels of Care Pediatric Home Health

Clinical Dates of Attendance: 6/6/2022 to 7/29/2022
Start Date End Date

Does this site require additional forms or spreadsheet to be submitted with TWU’s Attestation
Letter? Yes No N/A

If yes, make sure to complete the information that must be filled in by the student and submit as
an attachment with all of the required documents.

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 ATTESTATION LETTER REQUEST CHECKLIST

Section C – Externship Site Requirements

Please read each section carefully and do not leave any blanks, otherwise your form will be considered
incomplete and will not be processed.

CRITERIA Documentation to COMPLETED

Attach Date & Initials

Health & Liability Insurance Attach Student Liability

Card 04/26/2022
Students must attach a copy of their Liability Card that was
passed out during clinic orientation. AF
Current American Heart Assoc. BLS for Health Care Attach a copy of the
04/26/2022
Provider or Professional Rescuer AHA BLS card
AF
All students must have a current copy in their file. Please
document the date your CPR expires below.
Exp. Date: 07/2023
Criminal Background Check Attach report from
Castlebranch 04/26/2022
Student are responsible for scheduling and for any fees
associated with the background check. A copy of your report
AF
must be submitted with the Attestation Letter Request. If
the site did not specify, background check must have been
completed in the last 12 months.

Drug Screening Attach report from

04/26/2022
If the site did not refer the student to a laboratory for a Castlebranch
drug screen, the student is responsible for scheduling and for
AF
any fees associated with the drug screen. A copy of the drug
screen results must be submitted with the Attestation
Letter Request. If the site did not specify, the drug screen must
have been completed in the last 12 months.

DO NOT SUBMIT COPIES OF YOUR IMMUNIZATION RECORDS OR FLU/COVID VACCINES

WITH YOUR REQUEST. THESE RECORDS MUST BE UPLOADED TO THE TWU STUDENT
HEALTH PORTAL FOR VERIFICATION. ONCE VERIFIED, STUDENT HEALTH WILL CREATE
A TWU IMMUNIZATION RECORD. SUBMIT THE TWU IMMUNIZATION RECORD AS PROOF.

Flu (Influenza) Vaccine Attach TWU

Immunization Record 04/26/2022 AF
Current Immunization: MMR, Hepatitis B, TDaP, Attach TWU
04/26/2022
Varicella & Tuberculin Test Immunization Record
AF
COVID TEST AND/OR VACCINE Attach TWU
Immunization Record 04/26/2022 AF

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Last updated
4/26/2022