Instructor Application For Cna, Cma And Hha Training Courses printable pdf download

KANSAS DEPARTMENT FOR AGING AND DISABILITY SERVICES

INSTRUCTOR APPLICATION FOR CNA, CMA AND HHA TRAINING COURSES

Mark type of course.

G Nurse Aide Curriculum

G Home Health Aide Curriculum

G Medication Aide Curriculum

KDHE OFFICE USE ONLY

Instructor ID #

CNA

Approval Date

Disapproval Date

Reviewer Signature

CMA

Approval Date

Disapproval Date

HHA

Approval Date

Disapproval Date

Following approval, please use the six-digit Instructor ID# which has been assigned by the department. Include the assigned Instructor ID# on all

future correspondence with the department.

Type or print all information that is requested. This application should be received by this department at least three weeks prior to offering an initial

nurse aide, home health aide, or medication aide continuing education course.

APPLICANT, PLEASE NOTE: The attached CNA-CMA-HHA Instructor Employment Verification forms must be completed by current/former

employer(s) for each reference listed on the application. All employment verifications must be received by Health Occupations Credentialing before the

application can be processed.

Applicant Information

Name

First

Last

Other

Social Security Number

Date of Birth

Mailing Address

Street

City

State

Zip

Home Address

Street

City

State

Zip

Phone # (home) (

)

(work) (

)

CNA ID number (if applicable)______________

E-mail address _______________________________________________________

Kansas Licensure # (LPN/RN)

Expiration Date

- __

Instructor Qualifications:

NURSE AIDE INSTRUCTOR:

According to state and federal standards, each course instructor must be a registered nurse with a current Kansas license and have a minimum of

two years' licensed nursing experience. Additionally, all nurse aide instructors must have completed a course in teaching adults or a professional

continuing education offering on supervision or adult education, or shall have experience in teaching adults or supervising nurse aides and have

and completed at least seven hours of professional continuing education offerings on person-centered care in an adult care home or a long-term care

unit of a hospital not more than one year before becoming an instructor of the nurse aide training course and each year while serving as an instructor.

To document alternative long-term care setting: AAlternative Practice Setting Experience@ form is available upon request.

HOME HEALTH AIDE INSTRUCTOR:

According to state and federal standards, each instructor of a home health aide course must be a registered nurse with a current Kansas license and

have direct work experience in the provision of home health care. In order to qualify as an approved instructor, the state requires that the candidate

be a registered nurse with a minimum of two years= licensed nursing experience. At least 1,750 hours must be as a licensed nurse in home health

care services.

To document alternative home health care setting: AAlternative Practice Setting Experience@ form is available upon request.

MEDICATION AIDE INSTRUCTOR:

Each instructor must be a registered nurse with a current Kansas license and have two years full-time clinical experience as a registered nurse.

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