Form Dhhs/dhsr-8 - Nurse Aide I Training Faculty Requirements Worksheet - N.c. Department Of Health And Human Services Page 2

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FACULTY APPROVAL REQUEST FORM
North Carolina Division of Health Service Regulation
Please use this form as a template to make additional copies. Any time you add faculty, a new form must be completed and
submitted to DHSR for approval. To remove faculty, please use the Faculty Removal Form ( ).
School/Facility:
Mailing Address:
City:
County:
Zip Code:
Program Coordinator’s Area Code/Phone #:
Direct Extension:
Program Coordinator’s E-mail Address:
Area Code/Fax Line #:
Enter All Applicable Program Numbers Below
Nurse Aide I Program Number(s):
Geriatric Aide Program Number(s):
Refresher Course Program Number(s):
Home Care Aide Program Number(s):
(
)
Refer to Page 2 of Home Care Aide program application
Applicant’s Name as it appears on RN License
Position(s) Requested
(Please check all boxes that apply)
(Please Print Name
)
Program Coordinator for NAT
First:
Program Coordinator for Refresher
Middle:
Instructor
Last:
N.C. License OR
Other state license:
RN License #: ______________
Compact State License: Which state? _______
____________
Permanent or
Temporary
License Expiration
License is free from
(*Note: If temporary NC RN # is assigned, DHSR must
Date:
Charges/Discipline Against:
be notified when permanent NC RN license # is issued)
______________
Yes
No
Date of Original RN Licensure (Month/Year):
State of Original Licensure:
N.C. Board of Nursing Confirmation #______________________________ Date: ______________________
I certify that the information in this application is correct and accurate to the best of my knowledge and that the minimum
requirements for the position(s) requested have been met.
Signature: __________________________________________________________
Date: ______________
Applicant
Signature: __________________________________________________________
Date: ______________
Nurse Aide I Program Coordinator/Administrator/Director of Nursing
Printed: ____________________________________________________________
Nurse Aide I Program Coordinator/Administrator/Director of Nursing
A Program Coordinator or RN Administrator/Owner signature is required for all proprietary schools.
Signature: ___________________________________________________
Date: ______________
DHHS/DHSR-8 (Rev. 3-2015)
1

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