Form 08-4020a - Nursing Home Administrator Work Experience Verification printable pdf download

Form 08-4020a - Nursing Home Administrator Work Experience Verification

NHA

Alaska Department of Community and Economic Development

Division of Occupational Licensing

Nursing Home Administrator Section

P.O. Box 110806, Juneau, Alaska 99811-0806

(907) 465-2695

E-mail: license@dced.state.ak.us

NURSING HOME ADMINISTRATOR WORK EXPERIENCE VERIFICATION

PART I

INSTRUCTIONS TO APPLICANT: Type or print the information needed to complete Part I of this form. Forward the form to

a current or former employer(s) who supervised you in the health care institution. The information requested below must be

verified by the supervising employer. The blank form may be photocopied for additional requests. Upon completion of Part II,

the employer must return the form directly to the Division of Occupational Licensing.

, am applying for a license to practice as a Nursing Home

Administrator in Alaska and authorize you to release information as required of this form.

Signature

SSN

Address

Employment Dates

PLEASE DO NOT DETACH

PART II

INSTRUCTIONS TO EMPLOYER: Please complete this form and return it directly to the Division of Occupational

Licensing at the address at the top of the page. The verification is not to be returned to the applicant.

1. Employee’s position:

2. Dates you supervised employee:

3. Location where you supervised employee:

4. Your rating of employee’s ability:

Please provide details regarding the employee’s responsibilities, number of employees the applicant supervised, size of the

budget the applicant administered, and his/her financial experience. 12 AAC 46.010 requires documentation of a minimum

of 12 months (months = at least 40 hours of service during a month) of experience under the supervision of a health care

facility administrator. The applicant’s experience must be in institutional management in a health care facility and include

general administration techniques; fiscal, personnel, and physical facility management; client care issues; federal and state

regulations; and public relations.

Signature:

Title:

Printed Name:

Date:

Agency Name:

Mailing Address:

08-4020a (Rev. 2/00)

(3)

Form 08-4020a - Nursing Home Administrator Work Experience Verification