Form 08-4020c - Administrator In Training (Ait) Verification Form printable pdf download

Form 08-4020c - Administrator In Training (Ait) Verification 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) VERIFICATION FORM

PART I

Applicant’s Section: Type or print the information needed to complete Part I of this form. Forward the form to your preceptor

for completion of Part II. Upon completion of Part II, the preceptor must return the form directly to the Division of Occupational

Licensing.

Name

Last

First

Middle

Maiden/Other

Mailing Address

City

State

ZIP Code

Social Security Number

Birthdate

Signature

Date

PLEASE DO NOT DETACH

PART II

Preceptor’s Section: Please complete Part II of 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.

, certify that I have supervised the training activities and completion of forms

print preceptor’s name

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

applicant’s name

Training activities were conducted at

name of nursing home

beginning on

and ending

(a period of not less than

six months nor more than two years from the date the AIT Program Proposal was submitted to the Alaska Division of

Occupational Licensing), and included weekly supervisory conferences with the AIT to monitor the AIT’s education, and

completion of all training activities and forms provided in the “Five-Step Program.”

Preceptor’s Signature

Date

08-4020c (Rev. 2/00)

(5)

Form 08-4020c - Administrator In Training (Ait) Verification Form

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