Form Dhhs/dhsr-8 - Nurse Aide I Training Faculty Requirements Worksheet - N.c. Department Of Health And Human Services Page 4

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Name of Applicant: ________________________________________
III. REGISTERED NURSING EMPLOYMENT HISTORY CON’T.
Dates: From:
To:
( Month/Day/Year)
(Month/Day/Year)
Facility:
Position:
Type of Facility
Full time
:
Address:
Part time: __________ (# of hours/week)
City/State/Zip:
Area Code/Phone:
Check all boxes that apply to this experience:
Nursing Home
ICF/MR
Med/Surg
Hospital SNF
Home Care/Home Health/Hospice
Swing Bed Unit
Supervised NAs as part of job
Cared for chronically ill or elderly
Other (specify)
IV. ADULT TEACHING EXPERIENCE
Dates: From:
To:
(Month/Day/Year)
(Month/Day/Year)
Facility:
Describe teaching experience:
Address:
City/State/Zip:
Area Code/Phone:
Dates: From:
To:
(Month/Day/Year)
(Month/Day/Year)
Facility:
Describe teaching experience:
Address:
City/State/Zip:
Area Code/Phone:
V. TEACHING METHODOLOGY COURSE
Sponsored by:
Address:
Course content:
Date completed:
VI. ADDITIONAL INFORMATION YOU MAY WANT CONSIDERED RELATED TO THE REQUIREMENTS:
Complete and fax each form separately to 919-733-9764.
DHHS/DHSR-8 (Rev. 3-2015)
3

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