Doula Training Verification Form


A staff person at the training organization is being asked to complete this form to verify that the doula certification applicant has successfully completed a doula training with your organization. This training verification form is being submitted by the applicant to the Illinois Medicaid-Certified Doula Initiative. By submitting this document, the person completing the document is attesting that all information is true and accurate.

 

Applicant's Information

 
 
 
 
 
 
 
 

 

Training Agency

 
 
 
 
 
 
 
 
 
Phone
 

 

Training Components

 

(Check all training components that were provided in your organization's training program to the doula certification applicant)

 
 

 

Verification Details

 
 

Fill in this information if the training program collaborated with a health care organization. Skip these questions if they are not applicable.

 
 
 
 

 
 
 
 
 

 
 
 
 
 
 
 

 
Drop your files here