Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62687 (11/08)

STATE OF WISCONSIN
Chapter 146.40, Wis. Stats. HFS 129, Wis. Admin. Code

NURSE AIDE TRAINING PROGRAM TRAINER 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 nurse aide program trainers 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 program trainer eligibility requirements have been met. Providing the program trainer's social security number is voluntary; however, social security numbers are on 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. Provide the requested information for all trainers. Add any information that you believe is pertinent. (Submit additional pages, if necessary.) Submit completed application and materials to: Wisconsin Nurse Aide Training Consultant Office of Caregiver Quality P.O. Box 2969 Madison, WI 53701-2969

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If you have questions about completing this form, call (608) 261-8319.

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Print clearly 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 applicable Wisconsin license.

· Provide a copy of completed BID, DOJ, and DHS Responses if you will be participating in clinicals with the students. Note: To be approved as a program trainer, state and federal regulations require that you have a minimum of one year of experience in the area in which you will provide training.
Full Name (Last, First, MI) (DO NOT USE NICKNAMES.) Name - Program Title Social Security Number Sex

Female II. EDUCATION
Name ­ School / College Years Attended

Male

Year of Graduation

Diploma or Degree

Year Received

Street Address

City

State

Zip Code

III. WORK EXPERIENCE
Name ­ Employer Street Address City State Zip Code

Position Held

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

IV. LICENSURE (Attach additional pages, if necessary.)
Type of License (Attach copy of license.) State of Issuance Issuance Date (mm/dd/yyyy) Expiration Date (mm/dd/yyyy)

DHS OFFICE USE ONLY Program Trainer Approved
Reason for Denial

Approval Pending - Information Needed

Program Trainer Denied

Name ­ Reviewer

Title

Date Reviewed