Form 08-4020b - Administrator In Training (Ait) Program Proposal Form printable pdf download

Form 08-4020b - Administrator In Training (Ait) Program Proposal Form

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

ADMINISTRATOR IN TRAINING (AIT) PROGRAM PROPOSAL FORM

An applicant for a nursing home administrator license may meet the training and experience requirements of 12 AAC 46.010

by satisfactorily completing an Administrator-In-Training (AIT) program that meets the following requirements:

(1) be conducted under the guidance and supervision of a preceptor who meets the requirements of 12 AAC 46.051;

(2) require completion of all the activities and forms provided in the NAB Five-Step Program Administrator in Training

Internship Manual (1997 Edition);

(3) be a minimum of six months in duration; and

(4) be completed within two years of the date that the AIT program proposal is submitted to the department.

Before beginning an AIT program, the following must be completed and submitted to the division:

, certify that I will supervise the training activities

print preceptor’s name

and completion of forms provided in the NAB Five-Step Program Administrator in Training Internship Manual (1997 ed.), of

in not less than six months nor more than two years

applicant’s name

from the date the AIT Program Proposal is submitted to the Division of Occupational Licensing. I currently hold

license #

state of licensure

expiration date:

and I am currently employed in the administrative position of

, the nursing home where the AIT is completing training

activities. I agree to fulfill the duties and responsibilities of preceptor as outlined in the “Five-Step Program,” including weekly

supervisory conferences with the AIT to monitor the AIT’s education and training activities.

The anticipated dates of completion of each AIT activity:

Applicant’s Signature

Preceptor’s Signature

Date

08-4020b (Rev. 2/00)

(4)

Form 08-4020b - Administrator In Training (Ait) Program Proposal Form