Attestation Form for "Birth Equity (Dignity in Pregnancy & Childbirth)" Training

CA Dignity in Pregnancy and Childbirth Act; Implicit Bias Training

This is an attestation of completion of the "Dignity in Pregnancy & Childbirth; Preventing Racial Bias in Perinatal Care" training from Diversity Science. The training can be found here: https://www.diversityscience.org/perinatal-care-equity/ . (Note: Please be sure to save your completion certificate for your own records.)

By checking the relevant fields and writing my name below, I attest that I have completed this training.

Question Title

* 1. Confirm:

I attest that I have completed this training.

Question Title

* 2. Provider/Staff Name

Question Title

* 3. Clinic/Office Name

Question Title

* 4. Clinic/Office Address

Question Title

* 5. NPI or Group Tax Identification Number (TIN)

Question Title

* 6. Provider/Staff Email Address

Question Title

* 7. Comments/Suggestions

Question Title

* 8. Add Certificate

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File