Form LIC9140 "Request for Course Approval - Administrator Certification Program" - California

What Is Form LIC9140?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2016;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LIC9140 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC9140 "Request for Course Approval - Administrator Certification Program" - California

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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)
PAGE 1 OF 2
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)
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Name of Proposed Instructor:
Social Security Number:*
I
I
(6) Does the individual currently hold or previously held a license, certification or other approval as a professional in a specified
YES
NO
field (e.g., RN, NHA)? If yes, please list the type(s) of license(s) or certificate(s) and their number(s). (Include any
Administrator Certificates.)
I
I
(7) Does the individual currently hold or previously held a State-issued care facility license? If yes, please list the type of license(s)
YES
NO
and license number(s). (Include any community care facility licenses.)
I
I
(8) Is the individual currently employed or previously employed by a State-licensed care facility? If yes, please list the facility
YES
NO
name(s) and license number(s). (Place an * by those where currently employed.)
I
I
(9) Has the individual been the subject of any legal, administrative, or other action involving licensure, certification or other
YES
NO
approvals as specified in (6), (7), and (8) above? If yes, please explain and provide the date(s). (Include any Administrative
Actions. Attach additional pages if more space is needed.)
(10) I declare that the foregoing information is true and correct to the best of my knowledge.
Signature
Date
Name of Proposed Instructor:
Social Security Number:*
I
I
(6) Does the individual currently hold or previously held a license, certification or other approval as a professional in a specified
YES
NO
field (e.g., RN, NHA)? If yes, please list the type(s) of license(s) or certificate(s) and their number(s). (Include any
Administrator Certificates.)
I
I
(7) Does the individual currently hold or previously held a State-issued care facility license? If yes, please list the type of license(s)
YES
NO
and license number(s). (Include any community care facility licenses.)
I
I
(8) Is the individual currently employed or previously employed by a State-licensed care facility? If yes, please list the facility
YES
NO
name(s) and license number(s). (Place an * by those where currently employed.)
I
I
(9) Has the individual been the subject of any legal, administrative, or other action involving licensure, certification or other
YES
NO
approvals as specified in (6), (7), and (8) above? If yes, please explain and provide the date(s). (Include any Administrative
Actions. Attach additional pages if more space is needed.)
(10) I declare that the foregoing information is true and correct to the best of my knowledge.
Signature
Date
Name of Proposed Instructor:
Social Security Number:*
I
I
(6) Does the individual currently hold or previously held a license, certification or other approval as a professional in a specified
YES
NO
field (e.g., RN, NHA)? If yes, please list the type(s) of license(s) or certificate(s) and their number(s). (Include any
Administrator Certificates.)
I
I
(7) Does the individual currently hold or previously held a State-issued care facility license? If yes, please list the type of license(s)
YES
NO
and license number(s). (Include any community care facility licenses.)
I
I
(8) Is the individual currently employed or previously employed by a State-licensed care facility? If yes, please list the facility
YES
NO
name(s) and license number(s). (Place an * by those where currently employed.)
I
I
(9) Has the individual been the subject of any legal, administrative, or other action involving licensure, certification or other
YES
NO
approvals as specified in (6), (7), and (8) above? If yes, please explain and provide the date(s). (Include any Administrative
Actions. Attach additional pages if more space is needed.)
(10) I declare that the foregoing information is true and correct to the best of my knowledge.
Signature
Date
* Optional but requested for CDSS use only to assist in verifying identity and licensing affiliations. Federal law (at Title 5 United States Code Section 552a Note) states that:
Any federal, state, or local government agency which requests an individual to disclose his social security account number shall inform that individual whether that disclosure
is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it.
LIC 9140 (11/16)
PAGE 2 OF 2
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