Program Coordinator Application Form printable pdf download

Program Coordinator Application Form

UTAH NURSING ASSISTANT REGISTRY

550 East 300 South

Kaysville, Utah 84037

Phone: 801- 547-9947

Fax: 801-593-2584

PROGRAM COORDINATOR APPLICATION

This form must be submitted when an individual is requesting approval to be the Program Coordinator, to

replace a Program Coordinator or when applying for program renewal of an approved Nursing Assistant

Training Program in the state of UTAH.

Facility/Agency Name and Address

________________________________________

NAME OF PROGRAM COORDINATOR: ___________________________________

(Attach copy of current RN license and resume)

1. Completed a UNAR approved “Train the Trainer” program prior to

approval of the nursing assistant training program or meets requirements for waiver. If new

coordinator, please attach copy of certificate or proof of experience.

2. The Program Coordinator in a nursing facility-based program may be the director of nursing for

the facility as long as the facility remains in full compliance with OBRA requirements and will be

relieved of their duties as DON if they will be teaching in the program. Is the Program Coordinator

the Director of Nursing? ____________.

3. There is attached documentation that verifies the Program Coordinator meets all requirements

in the UNAR Program Coordinator job description.

4. The Program Coordinator must have a minimum of 3 hours per month of documented

supervision of the program.

Day Telephone number _____________ E-mail address ________________________

I certify the above information is correct:

Applicant Printed Name ___________________________________

Applicant Signature _________________________________ Date ________________

(Please make a copy of this application for your files so you have the information for

further reference)

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Program Coordinator Application Form