Regional Alliance for Firefighter Training

Regional Alliance for Firefighter Training

5967 Bedford Place, Ann Arbor, MI 48105

(313) 653-2320 • info@raft911.org • www.raft911.org

Health and 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
Below are your six randomly selected required skill sheet numbers.

Skill sheets can be found at https://www.raft911.org/HSOSheets/

• • • • •

Applicant's Validation Statement

I verify that I have completed the requisite skill sheets provided by RAFT for my HEALTH &
INCIDENT SAFETY OFFICER certification. I am only required to return this affidavit, but I
understand that RAFT or The Pro Board may conduct random audits, requesting to see the
completed sheets.

Applicant's Signature: ________________________________________ Date: _______________

Employer Skills Validation Statement (Required)

I verify that I am a Chief Officer or Supervisor within the above applicant’s agency and that said applicant has completed requisite skills sheets developed by RAFT as written in NFPA 1550, Standard for Emergency Responder Health and Safety (2024).

Print Name: __________________________________________________ Title: ________________

Signature: ___________________________________________________ Date: _______________

Return a PDF copy of this completed & signed affidavit to our office via email.
A Pro Board certificate will not be issued until we have the signed Affidavit on-file.