Form Sr 2a-Ctf-Nurse - Child Care And Supervision Component Program Worksheet
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2STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CHILD CARE AND SUPERVISION COMPONENT
PROGRAM WORKSHEET
PROVIDER NAME:
PROGRAM NUMBER:
MONTH/YEAR:
(SR 2A-CTF-NURSE)
Column
Column C
Column
Column
Column
Column
Education/Experience
B
A
F
D
E
Nurses
Lic. RN w/2 yrs
Training
Lic Pysch. Tech. 2 yr
Lic. RN
Lic RN w/MA
Weighting
Total
Nur. Adm or supv &
40 + hours
Paid-
LVN
FT exper. w/persons
Licensed
2 yrs. Exper.
Psych. Nurse or
1.0 + Cols.
Weighted
Verified
1 yr. Psych.
per
Awake
w/mental disabilities
Psych Nursing
related field w/admin. exp.
RN
C & D
Hours
Hours
Nursing
year/FTE
Hours
0.50
0.50
2.40
2.40
2.40
0.60
(Max = 4.0)
Col A x E
1.00
TOTAL:
TOTAL:
FCARB REP:
DATE:
GROUP HOME REP:
SR 2A-CTF-NURSE (12/02)
Page ____ of ____
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