"Provisional Licensee Reporting Form" - Texas

Provisional Licensee Reporting Form is a legal document that was released by the Texas Funeral Service Commission - a government authority operating within Texas.

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Texas Funeral Service Commission

Provisional Licensee Reporting Form

Guidelines for Supervision:

 It is the responsibility of the FDIC/EIC to arrange and ensure that direct supervision is provided to each provisional licensee under his or her

employment. Failure to do so may be considered a violation and may result in disciplinary actions against all licensees involved.

 Funeral Director Only Licensees may NOT supervise Provisional Embalmer Licensees and Embalmer Only Licensees may NOT supervise

Provisional Funeral Director Licensees.

 Provisional Licensees must complete a total of 45 cases in order to complete the Provisional License Program. Of those 45 cases, at least 10

must be complete cases. A complete funeral directing case consists of all major actions from the time of first call through interment or other

disposition of the body; a complete embalming case requires the provisional embalmer to handle all major actions included in TAC §203.16

(relating to Requirements Relating to Embalming) performed on a particular body.

 The Provisional Licensee is required to retain copies and the FDIC/EIC is required to retain originals of all monthly reports with supporting

documentation for all case credit claimed for two years from the completion date of the Provisional License Program. All forms are subject to

inspection by the Commission and must be provided for inspection if requested. Failure to retain documentation may result in disciplinary

action.

 Provisional Licensees must file a report with the FDIC/EIC outlining the number of cases performed and the name of the Funeral Director or

Embalmer who was present when services were performed.

Form Instructions:

 Report Type: Separate forms must be used to record cases relating to funeral directing or embalming. Check appropriate line to indicate if

report is for funeral directing or for embalming.

 Name & License #: List Appropriate names and license numbers. Use a SEPARATE form for each Funeral Establishment worked in. Use a

SEPARATE form for each FDIC/EIC worked under. If the Funeral Establishment or FDIC/EIC changes, uses a SEPARATE form.

 Case #: Keep a running list of cases worked. Each page will allow licensee to report 12 cases of the 45 required. For example, first sheet

would be cases 1-12, second sheet would be cases 13-24, third sheet would be 25-36, etc. Highlight required 10 complete cases.

 Supervisor’s Printed Name & License #: Supervisor is a licensed Funeral Director or Embalmer that provides direct supervision for a case.

The Supervisor does NOT have to be the FDIC/EIC. It is strongly recommended that a Provisional Licensee have each supervisor sign the

form on the day the service was performed.

 Form may be used until filled even if the cases occur in different months AS LONG AS the Funeral Establishment and the FDIC/EIC remain

the same.

 If a Provisional Licensee moves to or adds a Funeral Establishment, a SEPARATE form must be started. If a FDIC/EIC changes, a

Provisional Licensee must start a SEPARATE form.

 Once a form is completed, sign the form and return to FDIC/EIC for signature.

Texas Funeral Service Commission

Provisional Licensee Reporting Form

Guidelines for Supervision:

 It is the responsibility of the FDIC/EIC to arrange and ensure that direct supervision is provided to each provisional licensee under his or her

employment. Failure to do so may be considered a violation and may result in disciplinary actions against all licensees involved.

 Funeral Director Only Licensees may NOT supervise Provisional Embalmer Licensees and Embalmer Only Licensees may NOT supervise

Provisional Funeral Director Licensees.

 Provisional Licensees must complete a total of 45 cases in order to complete the Provisional License Program. Of those 45 cases, at least 10

must be complete cases. A complete funeral directing case consists of all major actions from the time of first call through interment or other

disposition of the body; a complete embalming case requires the provisional embalmer to handle all major actions included in TAC §203.16

(relating to Requirements Relating to Embalming) performed on a particular body.

 The Provisional Licensee is required to retain copies and the FDIC/EIC is required to retain originals of all monthly reports with supporting

documentation for all case credit claimed for two years from the completion date of the Provisional License Program. All forms are subject to

inspection by the Commission and must be provided for inspection if requested. Failure to retain documentation may result in disciplinary

action.

 Provisional Licensees must file a report with the FDIC/EIC outlining the number of cases performed and the name of the Funeral Director or

Embalmer who was present when services were performed.

Form Instructions:

 Report Type: Separate forms must be used to record cases relating to funeral directing or embalming. Check appropriate line to indicate if

report is for funeral directing or for embalming.

 Name & License #: List Appropriate names and license numbers. Use a SEPARATE form for each Funeral Establishment worked in. Use a

SEPARATE form for each FDIC/EIC worked under. If the Funeral Establishment or FDIC/EIC changes, uses a SEPARATE form.

 Case #: Keep a running list of cases worked. Each page will allow licensee to report 12 cases of the 45 required. For example, first sheet

would be cases 1-12, second sheet would be cases 13-24, third sheet would be 25-36, etc. Highlight required 10 complete cases.

 Supervisor’s Printed Name & License #: Supervisor is a licensed Funeral Director or Embalmer that provides direct supervision for a case.

The Supervisor does NOT have to be the FDIC/EIC. It is strongly recommended that a Provisional Licensee have each supervisor sign the

form on the day the service was performed.

 Form may be used until filled even if the cases occur in different months AS LONG AS the Funeral Establishment and the FDIC/EIC remain

the same.

 If a Provisional Licensee moves to or adds a Funeral Establishment, a SEPARATE form must be started. If a FDIC/EIC changes, a

Provisional Licensee must start a SEPARATE form.

 Once a form is completed, sign the form and return to FDIC/EIC for signature.

Texas Funeral Service Commission

Provisional Licensee Reporting Form

Report Type:

Funeral Director ___________

Embalmer ____________

Provisional Licensee Name: _________________________________________________ License # ___________

Funeral Establishment Name: ________________________________________________ License # _______

FDIC/EIC Name: _________________________________________________________ License #________

Supervisor’s Printed Name/License #

Case #

Date

Supervisor’s Signature*

Name of Deceased

1-45

Completed

(Not Always FDIC/EIC)

* I hereby certify that I was the licensed funeral director/embalmer that provided direct supervision on the case listed.

I hereby certify that I performed the above cases with supervision from the Funeral Director/Embalmer listed for each case.

____________________________________________

________________________________

Signature of Provisional Licensee

Date

I hereby certify that I was the FDIC/EIC responsible for supervision of the Provisional Licensee and I agree that the Funeral Director/Embalmer listed for each case was in the

room when services were performed.

___________________________________________

________________________________

Signature of FDIC / EIC

Date