The student's signature acknowledges receipt of the final remediation outcome and does not necessarily indicate agreement with the decision.
Student Name: ___________________________________________
Student Signature: ________________________________________
Date: ___________________________________________________
☐ Student declined or was unavailable to sign. Documentation of communication attached.
SECTION XI. FINAL FACULTY/PROGRAM SIGN-OFF The undersigned confirm that the remediation process has been documented and that the final outcome has been recorded in accordance with NLU PA Program policies and procedures.
Responsible Faculty Member
Name: ___________________________________________________
Title: ___________________________________________________
Signature: _______________________________________________
Date: ___________________________________________________
Director of Didactic Education, Director of Clinical Education, or Designee
Name: ___________________________________________________
Title: ___________________________________________________
Signature: _______________________________________________
Date: ___________________________________________________
Program Director or Designee
Name: ___________________________________________________
Title: ___________________________________________________
Signature: _______________________________________________
Date: ___________________________________________________
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