Free Notice of Substantial Change Feeding Assistant Training Program-F-62594 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62594 (11/08)

STATE OF WISCONSIN

NOTICE OF SUBSTANTIAL CHANGE FEEDING ASSISTANT TRAINING PROGRAM
· The purpose of this form is to provide the Division of Quality Assurance (DQA) with information, in a timely manner, regarding requests for changes in approved feeding assistant training programs. Substantial changes in the program must be reported to DQA in writing 10 days prior to the implementation of the change. The substantial change must not be implemented until the change is approved by DQA. DQA responds to substantial change notices in writing. · "Substantial change" is defined as any change in the primary instructor, curriculum, program site, or clinical site. · Failure to provide this information may result in the suspension or revocation of the program's certification or the imposition of a plan of correction on the program. · If you have any questions about the completion of this form, please contact the Office of Caregiver Quality at (608) 261-8328. · Submit this completed form to: Wisconsin Feeding Assistant Training Program Office of Caregiver Quality P.O. Box 2969 Madison, WI 53701-2969 FAX: (608) 264-6340

· Print neatly in BLACK INK or type.
Name ­ Program Program Approval Number

CHANGE
Program designee changed? If "yes," indicate date of change and attach details, including name, telephone number, and e-mail address. Primary instructor changed? If "yes," indicate date of change and attach details, including name, copy of current license, resume, Social Security Number, home address, telephone number. Program trainer changed? If "yes," indicate date of change and attach details. Program site (instructional or clinical) changed? If "yes," indicate date of change and attach details, including physical and mailing addresses, telephone number, FAX number. Training curriculum changed? If "yes," indicate date of change and attach details of curriculum change. Date (mm/dd/ccyy) Date (mm/dd/ccyy) Date (mm/dd/ccyy) Date (mm/dd/ccyy) Date (mm/dd/ccyy)

REASON FOR CHANGE (Identify page and section from attached application.)

PROGRAM REPRESENTATIVE
Name ­ Program Representative SIGNATURE ­ Program Representative Title Telephone Number FAX Number Date Signed

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

Name ­ Reviewer

Title

Date Reviewed