Attestation Form - Nc Radiation Protection

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ATTESTATION FORM
Regarding Requirements of the Mammography Quality Standards Act
Attestation must include as much of the following information as possible:
Name of the institution/facility where the applicable training or mammography
reading/interpreting, or other activity, took place; name of the course(s) or training
(where applicable); the attendance, reading/interpreting, or other activity dates; and the
supervising/responsible person (where applicable) for the institution/facility.
Please
provide these details in the space below. Attach additional sheets if necessary.
I ___________________________ attest that, to the best of my knowledge and my
belief, the following information provided in this declaration is true and correct. I
understand that FDA may request additional information to substantiate the
statements make in this declaration:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I understand that knowingly providing false information in a matter within the
jurisdiction of an agency of the United States could result in criminal liability,
punishable by up to $10,000 fine and imprisonment of up to five years, or civil
liability under the MQSA, or both
Attestor’s Signature and Title
________________________
Date signed
Facility Name and Address (if applicable) (including zip code):
___________________________________
___________________________________
___________________________________
Facility ID Number (if applicable) ______________________

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