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					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.