Free Feeding Assistant Training Program Primary Instructor Application-F-62692 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62692 (11/08)

STATE OF WISCONSIN
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FEEDING ASSISTANT TRAINING PROGRAM PRIMARY INSTRUCTOR APPLICATION

· The U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) authorizes the Department of Health Services to review and determine eligibility for feeding assistant primary instructors under the requirements of the Medicare and Medicaid programs. Completion of this form is voluntary; however, the information collected on this form is used to determine if federal and state primary instructor eligibility requirements have been met. · Providing the primary instructor's social security number is voluntary; however, social security numbers are one of the unique identifiers used to prevent incorrect identity mismatches; e.g., the Department of Justice uses social security numbers, names, gender, race, and date of birth to prevent incorrect matches of persons with criminal convictions. · Complete and mail this form to: Wisconsin Feeding Assistant Training Consultant Office of Caregiver Quality P.O. Box 2969 Madison, WI 53701-2969 · Print neatly in BLACK INK or type.

I. PERSONAL INFORMATION · Provide a copy of your Social Security card and a form of identification to verify your current name. · Provide a copy of your current Wisconsin license. NOTE: To be approved as a feeding assistant primary instructor, state and federal regulations require that you are currently licensed to practice in your respective field in Wisconsin.
Full Name (Do not use nicknames.) Last Social Security Number Title First M.I. Wisconsin License Number Sex Female Current Mailing Address (Street / P.O. Box) City State Zip Code Male

Telephone Number (Home)

Telephone Number (Work)

E-mail Address

Name ­ Training Program You Intend to Instruct

II. EDUCATION
Name ­ School / College Year of Graduation

Street Address

City

State

Zip Code

III. CREDENTIALS (Attach copy of license / credential. Attach additional pages, if necessary.)
Type of License / Credential State of Issue Date Issued (mm/dd/yyyy) Expiration Date (mm/dd/yyyy)

F-62692 (Rev. 11/08)

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IV. HEALTH CARE EMPLOYMENT INFORMATION Attach a copy of your resume or complete the area below to verify your work history in meeting clients' eating and hydration needs. List the names and locations of the health care facilities at which you have been employed, as well as the dates of employment. Include the type of health care facility.
Name and Location ­ Health Care Facility Employment Dates From: Nursing Home Home Health Agency Hospital ICR/MR Hospice Other Facility Type

To:

From:

Nursing Home Home Health Agency Hospital

ICR/MR Hospice Other

To: From: Nursing Home Home Health Agency Hospital ICR/MR Hospice Other

To:

From: Nursing Home Home Health Agency Hospital ICR/MR Hospice Other

To:

Attach additional page(s), if needed, for the following items. 1. List specific job duties.

2. List and describe employment in providing feeding and hydration to clients.

3. List and describe health care experiences (if applicable).

DHS USE ONLY
Primary Instructor Approved Approval Pending, Information Needed Primary Instructor Denied Reason for Denial: Entered Database Date:

Name ­ Reviewer

Title

Date Reviewed