Form Lic 9140 - Request For Course Approval - Administrator Certification Program

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
REQUEST FOR COURSE APPROVAL
ADMINISTRATOR CERTIFICATION PROGRAM
INSTRUCTIONS: At least 60 days before the planned offering of an ICTP or CEU course for facility administrators, vendors must
submit this completed application to CDSS, ACS, 744 “P” Street, MS 9-14-47, Sacramento, CA 95814. Submit a separate application
for each course.
(1) Type of Program and Vendorship: (Select one box.)
I
I
I
I
I
I
I
I
STRTP ICTP
ARF ICTP
GH ICTP
RCFE ICTP
ARF CEU
GH CEU
RCFE CEU
STRTP CEU
(725-1)
(735-1)
(730-1)
(740-1
(735-2)
(730-2)
(740-2)
(733-2)
(2) Vendor Information: (Please print.)
Vendor Number:
________________________________________________________
Organization/Vendor Business Name
:_______________________________________________________________________________
Address (Street Address, City, State, Zip):
____________________________________________________________________________
Authorized Representative/Contact Person (Name):
______________________________________________________________________
Business Phone Number: __________________ Fax:
E-mail:
_____________________
_______________________________________
(3) Course Information: (Please print.)
Course Number (if updating a previously approved one):
_______________________________
Proposed Course Title:
______________________________________________________________________________________________
Total Classroom Hours: _________ Date(s) to be Offered (if known): _____________________________ Fee:_____
___________
I
I
I
I
For CEU courses: Format: (Check one box.)
Classroom
Conference
Online
Webinar
Core of Knowledge category(ies):
________________________________________________________________________________
If online course or Webinar provide the necessary log-on information for course review:
__________________________________
I
I
Is this course proposed for co-location with another CEU course?
YES
NO
If yes, list the other course number, if already approved
or check
that other course application included.
__________________
I
I
I
I
For RCFE ICTPs: Format(s) of 20 hour section
Classroom
Online
Other____________________________
(4) Proposed Course Outline: (Attach a document including the following information.)
I
Instructor(s) Qualifications: Include a current resume of work experience, and complete Sections 6 – 10 on page 2 of this
form for each proposed instructor. Instructors must have knowledge and/or experience in the subject area to be taught per one of
the following criteria (check applicable one(s)):
I
Possession of a bachelor’s or higher degree and 2 years’ experience relevant to the course to be taught, or
I
Four years’ experience relevant to the course to be taught, or
I
Be a professional, in a related field, with a valid current license to practice in California, and 2 years’ related experience, or
I
Have at least 4 years’ experience in California as an administrator of a facility in substantial compliance, within the last 6
years, and verifiable training in the subject to be taught.
I
Description of Course: Briefly summarize the course including how it relates to the business operations and/or the care of
residents in the facility
.
I
Objective(s) of Course: Identify what the student is expected to know upon completion of this course.
I
Teaching Methods: Explain the types of teaching methods to be used.
I
Course Content: Outline the course content with hour-by-hour detail, and including the proposed instructor for each segment.
I
Method of Course Evaluation by Participants: Explain how participants will evaluate the course. Attach copy of proposed
form if available.
I
Method of Evaluating Participants: Explain how you will evaluate the participants. Attach copy of proposed post-test if
applicable.
I
Method of Verifying Active Student Participation for Course Duration (for online courses only).
I
Types of Records to be Maintained and Address Where Records are Maintained.
I
Address and/or Locality(ies) Where the Course Will Be Presented.
I
Make Up Policy (for ICTPs only).
(5) Vendor Certification: I declare that the foregoing information is true and correct to the best of my knowledge.
Signature of Vendor/Authorized Representative
Printed Name of Vendor/Authorized Representative
Title
Date:
DO NOT WRITE BELOW THIS LINE
Application has been
I
approved OR
I
disapproved by:
Date:
Expiration Date:
Approved Course Number
LIC 9140 (11/16)
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