Free Nurse Aide Training Program Primary Instructor Application, F-62610 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62610 (Rev. 07/08)

STATE OF WISCONSIN Chapter 146.40, Wis. Stats. HFS 129.06(1), Wis. Admin. Code Page 1 of 2

NURSE AIDE TRAINING PROGRAM PRIMARY INSTRUCTOR APPLICATION
· The US 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 nurse aide 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 Nurse Aide Training Consultant Division of Quality Assurance Office of Caregiver Quality P.O. Box 2969 Madison, WI 53701-2969

· Print neatly in BLACK INK or TYPE the following information.

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 nursing license Provide a copy of your completed HFS-64, Background Information Disclosure (BID); Department of Justice (DOJ) Criminal History response; and DHS responses to Caregiver Background Check letter.

NOTE: To be approved as a primary instructor, state and federal regulations require that you are a registered nurse, currently licensed to practice in Wisconsin
Full Name (Last, First, Middle Initial) DO NOT USE NICKNAMES. WI Nursing License Number

Social Security Number

Birth Date (mm/dd/yyyy)

Gender Female Male Zip Code

Current Mailing Address (Street Address / P.O. Box Number)

City

State

Home Telephone Number

Work Telephone Number

E-mail Address

Name of the Training Program You Intend to Instruct

II. EDUCATION
Provide a copy of your Train the Trainer certificate.
School / College Year of Graduation

School / College

Year of Graduation

School / College

Year of Graduation

Train the Trainer Course

Date of Graduation

Substantially Equivalent Training Course Description

Date of Training Graduation

F-62610 (Rev. 07/08)

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III. HEALTH CARE EMPLOYMENT INFORMATION
· · List the names and locations of all health care facilities at which you have been employed as a registered nurse, as well as the dates of employment. Check the appropriate box to indicate the type of health care facility. Attach a copy of your resume to verify your education, work history, and clinical experience in meeting clients' psychosocial, behavioral, cognitive, and physical needs.

NOTE: For primary instructor approval, state and federal regulations require that you have a minimum of two years experience working as a registered nurse, of which at least one year must be in the provision of long term care.
Name / Location ­ Health Care Facility Employment Dates From To Name / Location ­ Health Care Facility Employment Dates From To Name / Location ­ Health Care Facility Employment Dates From To Name / Location ­ Health Care Facility Employment Dates From To Facility Type Nursing Home Home Health Agency Hospital Facility Type Nursing Home Home Health Agency Hospital Facility Type Nursing Home Home Health Agency Hospital Facility Type Nursing Home Home Health Agency Hospital ICF/MR Hospice Other ICF/MR Hospice Other ICF/MR Hospice Other ICF/MR Hospice Other

1.

List specific job duties. (Attach separate page as needed.)

2.

List and describe employment in the care of the chronically ill.

3.

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

DHS USE ONLY
Primary Instructor Approved Approval Pending, Information Needed Primary Instructor Denied

If Denied, Reason for Denial: __________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ Name ­ Reviewer Title Date Reviewed