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SAMPLE TIMS TRAINER QUALIFICATION FORM
Please fill out this form when a candidate trainer successfully achieves qualification as a trainer.
Trainer Information
First Name: ____________________________________ National ID Number: __________________
Middle Name: ____________________________________ Payroll ID Number: __________________
Last Name: ____________________________________ Other ID: ____________________________
Date of Birth: _______/_______/_______
Day / Month / Year
Where do you primarily work?
Facility Name:
Line 1
Line 2
Country:
Province:
District:
City:
Postal Code:
Gender
Male
Female
Facility Type:
Hospital
Health Center/Clinic/Dispensary
Medical/Nursing/Midwifery/Other School
Training Center
Other
Facility Phone:
Fax:
Sponsor:
Government
NGO/Not-for-Profit
Private/Commercial/For Profit
Is This Person a Trainer? ❑
Trainer Type:
Languages (list languages the candidate speaks
fluently):
❑Qualified Clinical Trainer
❑Qualified Classroom Faculty
❑Qualified Clinical Preceptor
❑Qualified Advanced Trainer
❑Qualified Master Trainer
Trainer Type Acquired On:
_______/_______/_______
Day / Month / Year
Assessed/Qualified By: ______________________________________________________________________________
Current Trainer Skills
Date of Standardization
_____/_____/_____
Comments
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
TIMS User Manual
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