Nurse Delegation: Credentials And Training Verification (Page 2 of 2) in pdf

Instructions – Nurse Delegation: Credentials and Training Verification

All fields are required unless indicated “OPTIONAL”.

1. Client Name: Enter ND client’s name (last name, first name).

2. Date of Birth: Enter ND client’s date of birth (month, day, and year).

3. ID Setting: OPTIONAL – Enter client’s ID number as assigned by your business OR enter settings “AFH”, “ALF”, DDA

Program, “In-home”.

4. Long Term Care Worker’s Name: Enter name of Long Term Care Worker (print).

5. Credential Verification: If you use the internet site, print a copy of the results of this caregiver’s credential search. Mark

the box with an “X” and fasten copy to this form. If you do not use the internet site, complete A., B., and C. with the

proper dates and check “Registered” or “Certified”, as appropriate, for this individual.

6. Training Verification: Check the box and insert the date class was completed for the 9 hour class. Check the box and

insert the date class was completed for “Special Focus on Diabetes” (only if providing delegated insulin injections). If

caregiver is an NAR, NA-C or HCA, check the box and insert the date you verified that the appropriate basic caregiver

class was completed.

HCA are required to complete the 40 hours Basic Training of the 75 hour Home Care Aide Training if they are being

delegated prior to completion of their certification.

EXEMPT LONG TERM CARE WORKERS

The Long Term Care Worker employed sometime between January 1,2011 and January 6,2012 and DDA Long Term

Care Worker employed sometime before January 1, 2016 should have a letter from the employer who employed them,

stating they have completed basic training requirements in effect on the date of his or her hire. Basic training could be

the Revised Fundamental of Caregiving or Basic Training Core Competency (40 hours of 75 hour HCA-C).

Reminder – For an NA-R or HCA working in supported living or group training homes, DD-Basic Training (32 hours)

fulfills the requirement for RFOC. For an NA-R or HCA working in any other DD setting, or with HCS clients, a basic

caregiving class usually Basic Caregiver Training (Core Competency), RFOC (or modified FOC), must be completed

before performing a delegated task.

7. and 8.

RND Signature and Date: The delegating nurse signs and dates each caregiver entry.

NURSE DELEGATION: CREDENTIAL AND TRAINING VERIFICATION

DSHS 10-217 (REV. 03/2016)

Nurse Delegation: Credentials And Training Verification Page 2