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Application Form For Reinstatement - Kansas Department For Aging And Disability Services

Board of Adult Care Home Administrators

Application for Reinstatement

Kansas Adult Care Home Administrator License

A Kansas adult care home administrator license may be reinstated upon meeting requirements of K.S.A. 65-

3503(d) and K.A.R. 28-38-23. Please complete this application documenting at least 50 clock hours of continuing

education, with a minimum of 10 hours is in resident care and 30 hours in administration, and return it with

completed Information Inventory, proof of your social security number, and appropriate reinstatement and renewal

fees.

License #____________________

Social Security Number____________________________________

Name

Other name used

Address_____________________________________________________________________________________

City________________________________________ State___________________ Zip_____________________

Phone:

Work (_____)_______________________

Home(_____)_______________________________

RECORD OF CONTINUING EDUCATION CLOCK HOURS

Clock hours submitted for the purpose of reinstatement shall be earned within the licensure period immediately

preceding application for reinstatement.

PRIOR APPROVED PROGRAMS: record approval number, title, date and hours. You must submit verification

of attendance for all prior approved programs listed.

PROGRAMS NOT PRIOR APPROVED: record title, date and hours below. You must submit 1) course content,

2) objectives, 3) time frame of educational activity and 4) verification of attendance.. (Note - hours exclude time

allotted for regulations, breaks, lunch, business meetings, etc. Credit for full hour or half hour only)

Approval

Program Title

Date

Resident

Administration

Electives

Number

Care

10 hours

30 hours

maximum

minimum

10 hours

(Please complete the remainder of the application on the back of this page.)

Application Form For Reinstatement - Kansas Department For Aging And Disability Services