Free 52640.FH11 - Indiana

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AFFIDAVIT OF COMPLETION OF ADMINISTRATOR- IN-TRAINING PROGRAM
State Form 52640 (R / 12-08)

INDIANA STATE BOARD OF HEALTH FACILITY ADMINISTRATORS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected]

I, ____________________________________, do solemnly swear or affirm, under the penalties of perjury, that I have:
Printed name of preceptor

1. Supervised the administrator-in-training program of ____________________________________, for ____________ hours; 2. Familiarized the administrator-in-training with my duties and responsibilities; 3. Arranged for the administrator-in-training to be assigned responsibilities in and have an opportunity to observe each department; 4. Arranged for the administrator-in-training to serve a minimum of twenty (20) hours per week, no more than ten (10) hours daily, for each week during the internship; 5. Given personal instruction and assistance to the administrator-in-training and he / she has fulfilled the duties prescribed under 840 IAC 1-1-16; and 6. Met the requirements of the administrator-in-training program prescribed under 840 IAC 1-1-15.
Signature of preceptor Date (month, day, year)

I, ____________________________________, do solemnly swear or affirm, under the penalties of perjury, that I have:
Printed name of administrator-in-training

1. Served as an administrator-in-training for a minimum of six (6) months *, but no more than twelve (12) months, under the tutelage of ____________________________________; 2. Observed and became familiar with the duties and responsibilities of my preceptor and of being an administrator-in-training; 3. Been assigned responsibilities in each department with experience on every shift; 4. Served as an administrator-in-training a minimum of twenty (20) hours per week, no more than ten (10) hours daily, for each week during the internship; 5. Received personal instruction and assistance from my preceptor and my preceptor has fulfilled the duties prescribed under 840 IAC 1-1-17(c); and 6. Acquired a working knowledge of health facility administration and met the requirements of the administrator-in-training program described in 840 IAC 1-1-15. * or for a reduced amount of time as approved by the board under 840 IAC 1-1-4(g).
Signature of administrator-in-training Date (month, day, year)