Form F-00657 - Military Training Verification
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1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
.
F-00657 (08/2012)
MILITARY TRAINING VERIFICATION
• Prior to issuing approval to take the State of Wisconsin nurse aide competency examination, the Department of Health Services
reviews the training of all military personnel. Completion of this form is mandatory, as the information collected on this form is used to
determine if federal and state nurse aide training program requirements have been met by military personnel.
• To be eligible, you must complete the courses that satisfy all nurse aide training requirements and complete 32 hours of hand-on
clinical experience.
• In order to assist the department in determining if your training is substantially equivalent to the nurse aide training requirements
found in the Code of Federal Regulations CFR 42 part 431 and Wisconsin Administrative Rule DHS 129, the following documentation
is required:
•
Military Training Verification form with Sections I and II completed;
•
Service School Academic Reports including course start/end dates, course of study, and grade;
•
Certificates of Training for specific programs completed, such as apprenticeships, specialization courses, or hands-on training
courses;
•
Training documentation signed by your Unit’s Training Non-Commissioned Officer, and;
•
A written personal narrative as to why you feel your military education/training/experience has prepared you for this profession.
•
Submit these documents for verification and approval to: DQA / Office of Caregiver Quality
Nurse Aide Training Consultant
P.O. Box 2969
Madison, WI 53701-2969
•
Your Social Security Number is requested so as to facilitate the timely processing of this form and it is used for no other purpose.
The provision of your Social Security Number is voluntary.
I. PERSONAL INFORMATION
Name
Social Security Number
Telephone Number
Address
City
State
Zip Code
II. EDUCATION
Indicate the specific, completed, course number for the courses in which the following criteria was taught and in which the minimum of 32
hours of “hands on” clinical experience was obtained.
Aging Process:
Care of Cognitively Impaired:
Safety/Emergency Procedures:
Basic Nursing Skills:
Communication Skills:
Residents’ Rights:
Basic Restorative Skills:
Infection Control:
Death/Dying:
Personal Care Skills:
Clinical Course:
Name – Clinical Facility
Type of Clinical Facility
DHS USE ONLY
Approved
Approval Pending, Information Needed
Denied
Reason for Denial
Name – Reviewer
Title
Date
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