Texas Funeral Service Commission
SAMPLE FORM
P.O. Box 12217 Capitol Station Austin, TX 78711 512-936-2474 or 888-667-4881 fax 512-479-5064
PROVISIONAL FUNERAL DIRECTOR TRAINING REPORT
I. Instructions: Please fill out completely. Report must be postmarked by the 10th day of the following month during the provisional program. Any incomplete reports will be invalid and not count towards the provisional licensure requirements. Additionally, incomplete reports will not be returned to the licensee.
______MUST BE FILLED IN_____________________ _______ MUST BE FILLED IN ____
Printed Name
______ MUST BE FILLED IN ____________________
Provisional License Number
_______ MUST BE FILLED IN ____
Establishment Name Establishment Address City
Establishment License Number State Zip Phone
_______ MUST BE FILLED IN ___________________________________________________________________________
_______ MUST BE FILLED IN __________________________________________________________
Residence Address
City
State
Zip
Phone
II. Report for CASES DURING the MONTH of_______ MUST BE FILLED IN ____in the year 20________ III. Activities Performed: 1.* Arrangement Conference with Authorizing Agent 2.* Communicate Price Information and Give “Facts About Funerals” Publication 3.* Presented Funeral Merchandise 4.* 5.* 6.* 7.* 8.* 9.* 10.* 11.* 12.* 13.* 14.* Generate Funeral Purchase Agreement and Obtain Signatures Prepared/Filed Required Forms Arranged Shipment/Transfer to Crematory/Anatomical Donation Dressing, Casketing/Prep for Cremation Cosmeticize Remains Check For/Removal of Pacemaker or Other Implants Prepared/Assisted Cemetery Arrangements Assisted at Graveside Service/Alternative Disposition Assisted at Funeral/Memorial Service/Viewing 2nd Conference-Delivery/Release of Cremains Assisted with Opening/Closing of Grave
15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.
First Call First Call Removal of Remains Set Up Equipment Composed Obituary /Clergy Data Arranged Flowers Arranged for Clergy/Fraternal Organization Supervised Pallbearers or Instructed Pallbearers Arranged/Supervised Cortege Drove a Vehicle that was Used as Part of the Funeral Service Notwithstanding Transfer Cremains into Display Urn(s) or Alternative Container SIX OF THE ACTIVITIES WITH AN ASTERIK MUST BE REPORTED TO RECEIVE CREDIT FOR A CASE
IV. Cases: Name Of Deceased 1. ALL BOXES MUST BE FILLED IN OR NO CREDIT FOR THE CASE
Date
Activities Performed LIST THE ACTIVITIES PERFORMED
Must be listed
Printed Name & License Number Of Supervisor NAME & LICENSE # OF SUPERVISOR OR NO CREDIT
Supervisor’s Signature MUST BE SIGNED OR NO CREDIT GIVEN FOR THIS CASE
2. 3. 4. 5. 6. 7. 8. 9. 10.
*Must perform six (6) functions (burial or cremation) with an asterisk to receive credit for a case. *Must perform ten (10) of the above functions for a complete case. (Complete cases will only be counted towards the 10 required complete cases during the last three consecutive months of the provisional program.)
I affirm that I performed all tasks listed in this report:
______MUST BE FILLED IN__________________ Signature of Provisional Licensee
______MUST BE FILLED IN______ License Number
_MUST BE FILLED IN____ Date
I certify that the provisional licensee named above assisted in all listed tasks under my direct and personal supervision as a licensed funeral director. Comments (optional):
______MUST BE FILLED IN__________________ Signature of Sponsor or Supervisor
______MUST BE FILLED IN______ License Number
_MUST BE FILLED IN____ Date
In accordance with Texas Occupations Code 651.304 Employment Records, Texas Administrative Code Rule 203.6 Provisional Licensees, and Rule 203.27 Sponsors of Provisional Licensees. A copy of this report will be maintained for 2 years by the provisional licensee. Additionally, the funeral establishment will maintain a copy of this report for 2 years and which may be subject to an audit.