Fillable PCA Training Instructor Approval Request Form (State of Alaska)

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PCA Training Instructor Approval Request Form (State of Alaska)

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The PCA Training Instructor Approval Request Form (State of Alaska) form is 2 pages long and contains:

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550 W 8
th
Ave.
Anchorage, Alaska 99501
Phone: 907-269-3666
Fax: 907-269-3973
BILL WALKER, GOVERNOR
PCA Training Instructor Approval Request Form
(Use this form to request approval for the instructor)
1. Individual/Organization wanting to provide PCA training:
Name:
Address:
Phone #: Fax #:
Contact Person: Email:
2. Location of proposed training:
3. Describe why PCA training is needed in the area:
4. Number of students you propose to train:
5. Name of person(s) who will conduct the training (please list all instructors, the subject are
they will teach, and their qualifications to teach the subject are, attach resumes and current
occupational licenses or certifications):
6. Are you a new individual/organization wanting to provide PCA training and require the
approved 40-hour PCA curriculum packet?
yes no
If you are not a new training site, has your site received the approved 40-hour PCA curriculum
packet?
yes no (if no, DSDS will research and provide a copy if individual/organization
DSDS file supports non-receipt)
7. Do you plan to augment the basic training requirements with topics/issues important to your
PCA Training General Information Request Form Updated 06/02/2017
area or region?
Yes No
If yes, please describe what you plan to add to the standardized training:
Thank you for taking an interest in training personal care assistants. We look forward to
assisting you in providing PCA Training in your community. If you have any questions regarding
PCA training or the PCA Program in general, please feel free to contact us. Please submit this
form and any supplemental documents by mail or fax to the following:
Cassandra Lynch, Health Program Associate, Training
Division of Senior and Disabilities Services
550 W 8
th
Ave
Anchorage, Ak 99501
Phone: 1-800-478-9996 or 907-269-3666 Fax: 907-269-8164
Email: hss.dsdstraining@alaska.gov
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PCA Training Instructor Approval Request Form (State of Alaska)

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Completed 11 February 2021

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