LARA/BPL-NHAEDU (05/19)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status,
disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
CERTIFICATION OF NURSING HOME ADMINISTRATOR EDUCATION
Authority: 1978 PA 368
This form must be submitted directly to this office by your educational institution. If this form is submitted by the applicant, it will not be
accepted.
Applicant’s Name (First, Middle, Last)
Name of Educational Institution
Address of Educational Institution
CERTIFICATION AND SIGNATURE
I certify the applicant has completed instruction at an institution accredited by an accrediting agency recognized by the
Council for Higher Accreditation and the instruction included a minimum of 9 semester credits or 144 hours clock hours of
instruction and included all of the following subjects: Administrative management of a nursing home; Human resources
management in a nursing home; Financial management of a nursing home; State and federal laws and regulations regarding
the nursing home industry, operation of a nursing home, emergency preparedness, including Medicare and Medicaid
provider compliance with the requirements of the Life Safety Code, and the protection of patients’ health, safety , and welfare
in a nursing home; Gerontology or the aging process; and Identification of elder abuse and neglect.
_________________________________________________
____________________________________________
Signature of Program Director Date
_________________________________________________
Print or Type Name of Director (Seal) If academic institution has no seal, please indicate.
