Fillable SCHOOL NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM APPLICATION TYPE (California)

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SCHOOL NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM APPLICATION TYPE (California)

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___________________________________________________________
State of California- Health and Human Services Agency
California Department of Public Health (CDPH)
Licensing and Certification Program (L&C)
Aide and Technician Certification Section (ATCS)
Training Program Review Unit (TPRU)
MS 3301, P.O. Box 997416
Sacramento, CA 95899-7416
PHONE: (916) 327-2445 FAX: (916) 324-0901
TPRU@cdph.ca.gov
SCHOOL NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM APPLICATION
TYPE OR PRINT LEGIBLY. SEE REVERSE FOR INSTRUCTIONS
School Name and Mailing
Address: Provider Identification Training Number:
School Phone:
County:
School Theory Classroom Training Site Address: _________________________________________________________
(Only if different from the address listed above) ___________________________________________________________
NOTE: The Department shall be notified of any change of program content, hours, staff, and/or evaluation of student
learning for the certification training program thirty (30) days prior to the enactment, provided that the changes are approved
by the Department. Core curriculum content shall include all topics listed in California Code of Regulations, Title 22, Section
71835, and Code of Federal Regulations, Section 483.152.
All clinical training shall take place in a Skilled Nursing Facility or Intermediate Care Facility and shall be conducted
concurrently with classroom instruction. Clinical training shall be supervised by a licensed nurse free of other
responsibilities, and shall be onsite providing immediate (being present while the person being supervised demonstrates the
clinical skills) supervision of students. Supervised clinical training shall be during the hours of 6:00 a.m. to 8:00 p.m. During
clinical training, there shall be no more than fifteen (15) students to each instructor. The state approved Training Program
entity must provide both the theory and the clinical supervised training to their students.
Only one (1) training schedule will be operationalized for each Provider Identification Training Number. Issuance of the
Provider Identification Training Number is verified by the Department’s representative’s signature on page 2 of the
application, signifying that all forms and Training Program requirements have been met.
The ratio of licensed instructors to students for supervised clinical training shall not exceed 1 to 15. Sixteen (16) hours of
required federal training will be given prior to direct patient care.
Training Schedule (check one): DAYS PM WEEKENDS
Name of Curriculum Used:
Student Fees:
Theory Hours:
Clinical Hours:
We certify, under penalty of perjury under the laws of the State of California, that the foregoing is
true and correct.
______________________________________________________________________________________________________________________ ____________________________________________________________________________________________________
Signature of Registered Nurse Program Director Registered Nurse Program Director Email
______________________________________________________________________________________________________________________ ____________________________________________________________________________________________________
Signature of Owner/School Administrator Owner/School Administrator Email
______________________________________________________________________________________________________________________ ____________________________________________________________________________________________________
Date School Administrator phone including extension #
CDPH 276S (4/19) This form is available on our website at: California Department of Public Health Page 1 of 2
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State of California-Health and Human Services Agency
California Department of Public Health (CDPH)
Licensing and Certification Program (L&C)
Aide and Technician Certification Section (ATCS)
Training Program Review Unit (TPRU)
MS 3301, P.O. Box 997416
Sacramento, CA 95899-7416
PHONE: (916) 327-2445 FAX: (916) 324-0901
TPRU@Cdph.ca.gov
SCHOOL NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM APPLICATION
Module
Name of the Module
Theory Hours
Clinical Hours
Module I:
Introduction
Module II:
Patients' Rights
Module III:
Interpersonal Skills
Module IV:
Prevention & Management of Catastrophe & Unusual Occurrences
Module V:
Body Mechanics
Module VI:
Medical and Surgical Asepsis; Infection Control
Module VII:
Weights and Measures
Module VIII:
Patient Care Skills
Module IX:
Patient Care Procedures
Module X:
Vital Signs
Module XI:
Nutrition
Module XII:
Emergency Procedures
Module XIII:
Long – Term Care Patient
Module XIV:
Rehabilitative Nursing
Module XV:
Observation and Charting
Module XVI:
Death and Dying
Module XVII:
Abuse
Total hours
PLEASE SEND THE FOLLOWING MATERIALS WITH THIS APPLICATION FORM FOR REVIEW AND
CONSIDERATION REGARDING CERTIFICATION TRAINING PROGRAM APPROVAL:
1)
Four (4) sample lesson plans selected from different modules, one (1) of which shall be “Patient Care Skills,”
which shall include
:
a)
The student behavioral objective(s)
b)
A descriptive topic content with adequate detail (method, technique, procedure) to discern what is
tau
g
ht
c)
The method of teaching
d)
The method of evaluating knowledge and demonstrable skills
2)
Samples of the student record documenting the clinical training, including the skills return demonstration for
ea
ch trainee
:
a)
A listing of the duties
and skills the nurse assistant must
learn
b)
Space to record the date when the
nurse assistant performs each
duty/skill
c)
Spaces to note satisfactory or unsatisfactory
performance
d)
Signature of the
approved
Director of Staff Development /
Instructor
3)
A
sample of
the individual
student
record
used
for
documenting
theory,
including
the
modules,
c
omponents
of
the modules, and classroom hours spent on the
modules
.
4)
A
schedule
of
training which
lists
the theory
topics
and
hours
and
clinical
objectives
and
hours
for
the
en
tire
course. Classroom instruction and clinical training are taught in conjunction with one
another
.
5)
Clinical site ag
reement
(CDPH 276E).
6)
Application for RN, Program Director, DSD / Instruction
Application (CDPH
279).
California
Department of Public Health Use Only
Training Schedule Approved: DAYS PM WEEKEND
Class Schedule – Hours: Clinical Schedule – Hours:
Date:
Training Schedule Revision Date:
☐Approved By:
(CDPH,
ATCS, Training Program Review Unit Representative)
CDPH 276S (4/19)
This form is available on our website at: California Department of Public Health Page 2 of 2
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SCHOOL NURSE ASSISTANT CERTIFICATION TRAINING PROGRAM APPLICATION TYPE (California)

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Completed 16 February 2022

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