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 NFPA1521-2020

edition Standard for Fire Department Safety Officer Professional Qualifications.

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.