Health & Safety Officer Skills Validation Affidavit |
| Name: ___________________________________ | Last 4 SS#: _______________________________ |
| Agency: __________________________________ | Rank: ____________________________________ |
| Address: _________________________________ | Address 2: _______________________________ |
| City: _____________________________________ | State: _____________ Zip: ________________ |
| Phone: ___________________________________ | Email: ___________________________________ |
| Date of class attendance, if applicable: ________________________________________________ |
|
Required Skill Sheets |
| Skill sheets can be found at https://fdsoa.wildapricot.org/HSO-sheets/. |
•
•
•
•
•
| Applicant's Validation Statement (Required) |
|
I verify that I have completed the requisite skill sheets provided by the FDSOA for HSO |
| certification. I am only required to return this affidavit but I understand that the FDSOA |
| may conduct random audits and request completed skill sheets. |
| Candidate's Signature: ________________________________________ Date: _______________ |
| Employer Skills Validation Statement (Required) |
| I verify that I am a Chief Officer for the above applicant’s agency and the said applicant has |
| completed requisite skills sheets developed by the FDSOA as written in NFPA1521, |
| Standard for Fire Department Safety Officer Professional Qualifications (2020): |
| Print Name: __________________________________________________ Title: ________________ |
Signature: ___________________________________________________ Date: _______________ Certificates will not be issued until receipt of the signed affidavit within one year of the exam date. |