Geriatric Aide Training Program For Registry Listing Community College Approval Application Form - N.c. Department Of Health And Human Services

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Health Care Personnel Education and
2709 Mail Service Center
Phone: 919-855-3970
Credentialing Section
Raleigh, NC 27699-2709
Fax: 919-733-9764
Division of Health Service
N.C. Department of Health
Regulation
and Human Services
GERIATRIC AIDE TRAINING PROGRAM FOR REGISTRY LISTING
COMMUNITY COLLEGE APPROVAL APPLICATION
Community College Name:
Mailing Address:
Area Code/Telephone Number:
Area Code/Fax Number:
Program Coordinator’s E-mail address:
Site Address:
Note: Please complete all appropriate blanks. Incomplete forms will be returned.
REQUIRED HOURS:
Classroom Hours = 75 Clinical Hours = 25 Total Hours = 100
Specify Curriculum Type:  Continuing Education
 Curriculum
STATEMENT OF UNDERSTANDING
I understand that approval to offer this program is based on our agency using the state-approved geriatric
aide curriculum. I understand that I must teach, at a minimum, 75 hours of content, to include all modules
as written in the curriculum, and provide 25 hours of clinical as directed. I understand that students must
be listed on the Nurse Aide I Registry prior to attending the course. I further understand our agency may
be required to make modifications to this program as requested by North Carolina Division of Health
Service Regulation (DHSR). Modifications made by the state to the state-approved curriculum and
provided to our agency will be incorporated into the currently approved program under which our agency
operates.
I understand that a college must require a minimum numerical grade of 75 as the final theory grade and a
lab/activity grade of pass/fail.
I understand that changes in faculty or clinical sites must be approved by the DHSR prior to implementation.
I understand DHSR may withdraw approval of this training program if it determines that the program does not
meet state requirements.
I certify that class rosters with records of successful completion of the course will be made available to
DHSR upon request.
_______________________________________________________
__________________
Signature of Program Coordinator
Date
_____________________________________________________
__________________
Signature of Administrator
Date
DHHS/DHSR-4509 (Rev. 3-2015)

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