Nurse Delegation: Credentials And Training Verification
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2Nurse Delegation:
Credentials and Training Verification
4. LONG TERM CARE WORKER’S (LTCW) NAME (PRINT)
5. Credential Verification
Attach a copy of internet Provider Credential Search
OR COMPLETE THE FOLLOWING
A. RN Delegator has verified that the Long Term Care Worker is currently registered or certified in Washington state
and is in good standing without restriction. Date of verification:
B. Washington State Certificate/Registration Number for
NAR
NAC
HCA – C
C. Expiration Date:
Registered
Certified
6. Training Verification
Required for NAR, NAC, and HCA-C before delegating.
Nurse Delegation for Nursing Assistants (9 hours)
Date:
Nurse Delegation Special Focus on Diabetes class (3 hours)
Date:
(ONLY if providing delegated insulin injections)
Basic Caregiver Training class required for NAR’s before delegating:
Basic Training (Core Competency)
Date:
Revised Fundamentals of Caregiving (RFOC) or alternative DSHS approved course
Date:
DDA CORE Basic Training
Date:
DDA 32 hour letter
PRIDE Training (Foster Care setting)
Date:
Basic Training certificate required of HCA before delegating*:
NAR credential
Date:
* Dual credential is no longer required after the HCA becomes certified.
EXEMPT LONG TERM CARE WORKERS
The HCS LTCW employed sometime between January 1, 2011 and January 6, 2012 and the DDA LTCW employed
sometime before January 1, 2016 should have a letter from the employer who employed them stating they have
completed the basic training requirements in effect on the date of his or her hire.
Letter of employment verification
Date:
Basic Training (Core Competency) OR
Date:
Revised Fundamental of Caregiving (RFOC) Date:
DDA CORE basic
Date:
DDA 32 hour letter
Date:
7. RND SIGNATURE
8. DATE
To register concerns or complaints about Nurse Delegation, please call 1-800-562-6078
DISTRIBUTION: Copy in client chart and in RND file
NURSE DELEGATION: CREDENTIAL AND TRAINING VERIFICATION
DSHS 10-217 (REV. 03/2016)
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