Directions for Completing Evaluation of Director Qualifications
The LPA should fill out this form using the following instructions.
Type or print clearly using black ink. Retain the original form in the facility file at the District Office. Retain one copy in the
director’s personnel file at the licensed center and return a copy to the director. Attach (to each evaluation) copies of the forms
and documents identified below.
I. PERSONAL INFORMATION:
Name: Enter the name of the person applying for an evaluation of qualifications. Include first, middle, and last names.
Facility: Enter complete name, address, and number of facility where the evaluated individual is currently employed.
Components of Program: Check appropriate box(es).
II. EDUCATION/EXPERIENCE:
Check appropriate box and attach appropriate documentation.
III. QUALIFYING POSTSECONDARY COURSES:
Courses: Enter course number, number of units (specify semester or quarter units), and the college where credits were
earned. Indicate each course completed. Enter the total units for all courses completed. Enter any additional units required.
IV. QUALIFYING EXPERIENCE:
Employment: Enter the dates of employment; include month/day/year, as well as hours per day. List position(s) held,
employer(s)/address(es), and the total number of months, days, and/or years employed.
V. OTHER APPLICABLE EDUCATION/COURSES:
Complete if other additional education/course requirements are applicable based on new statutory/regulatory changes. If
not applicable, indicate N/A. Verification of course completion must be attached to this form. Indicate course title and date
of completion, and initial.
Exceptions: Check appropriate box. Attach exception if required.
Check the appropriate box(es), and date and sign for every area for which it has been determined that the director is
qualified under Title 22 licensing requirements.
