"Limited Lay Administration of Medications (Llam) Participant Prerequisite Checklist" - Delaware

This "Limited Lay Administration of Medications (Llam) Participant Prerequisite Checklist" is a part of the paperwork released by the Delaware Health and Social Services specifically for Delaware residents.

The latest fillable version of the document was released on March 1, 2018 and can be downloaded through the link below or found through the department's forms library.

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Download "Limited Lay Administration of Medications (Llam) Participant Prerequisite Checklist" - Delaware

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(Attachment B)
DELAWARE HEALTH AND SOCIAL SERVICES
DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES
COMMUNITY SERVICES
Limited Lay Administration of Medications (LLAM)
Participant Prerequisite Checklist
Participants in the Limited Lay Administration of Medication (LLAM) program must meet the following
criteria before attending the
required (check one) ___15-hour Limited Lay Administration of Medication
(LLAM) course for new participants / ___6-hour Limited Lay Administration of Medication (LLAM)
recertification course for renewing participants.
This completed checklist must be signed by the agency
administrator and MUST accompany participant to class for review by LLAM instructor. Appropriate
section below to be completed by agency. If participant is RENEWING, original/copy of most recent letter
of completion MUST accompany them to renewal class for verification. Participant and agency staff
signatures on this form indicate that the information contained on this form is true and correct to the best of
their knowledge. Agencies MUST keep a copy of this completed form in the employee’s file.
Participant Name:
Class Date(s):
CDS Logon ID #: ________________________ CPR Pending: Class date (New Staff ONLY):_______
New Participant
1. Participant is 18 years old or older
DOB:
Yes
No
2. Participant is current in CPR certification.
Yes
No
Date of expiration on CPR Card:
3. Participant can read, write and speak English
Yes
No
(as validated by agency policy)
4. Participant has demonstrated competency in basic math (addition, subtraction, metric, and apothecary).
Validated by administration of math exam with score of 80% or better by participating agency.
Date of Exam & Score: _____________________________________
Agency:
Date: __________________
______________________________________________
Participants Signature: ______________________________________________________________
Agency Administrator/Designee:
***************************************************************************************
Renewing Participant
1. Date of last LLAM class:
2. Participant is current in CPR certification.
Yes
No
Date of expiration on CPR card:
3. As of (date) ___________, the participant meets all criteria to take the LLAM recertification class.
Agency:
Date: ________________
Participants Signature: _____________________________________________________________
Agency Administrator/Designee:
Note:
Please bring a copy of the LLAM course manual, pen/pencil, and Photo
I.D. to class. LLAM manual s are to be provided by employing agency.
03/2018
(Attachment B)
DELAWARE HEALTH AND SOCIAL SERVICES
DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES
COMMUNITY SERVICES
Limited Lay Administration of Medications (LLAM)
Participant Prerequisite Checklist
Participants in the Limited Lay Administration of Medication (LLAM) program must meet the following
criteria before attending the
required (check one) ___15-hour Limited Lay Administration of Medication
(LLAM) course for new participants / ___6-hour Limited Lay Administration of Medication (LLAM)
recertification course for renewing participants.
This completed checklist must be signed by the agency
administrator and MUST accompany participant to class for review by LLAM instructor. Appropriate
section below to be completed by agency. If participant is RENEWING, original/copy of most recent letter
of completion MUST accompany them to renewal class for verification. Participant and agency staff
signatures on this form indicate that the information contained on this form is true and correct to the best of
their knowledge. Agencies MUST keep a copy of this completed form in the employee’s file.
Participant Name:
Class Date(s):
CDS Logon ID #: ________________________ CPR Pending: Class date (New Staff ONLY):_______
New Participant
1. Participant is 18 years old or older
DOB:
Yes
No
2. Participant is current in CPR certification.
Yes
No
Date of expiration on CPR Card:
3. Participant can read, write and speak English
Yes
No
(as validated by agency policy)
4. Participant has demonstrated competency in basic math (addition, subtraction, metric, and apothecary).
Validated by administration of math exam with score of 80% or better by participating agency.
Date of Exam & Score: _____________________________________
Agency:
Date: __________________
______________________________________________
Participants Signature: ______________________________________________________________
Agency Administrator/Designee:
***************************************************************************************
Renewing Participant
1. Date of last LLAM class:
2. Participant is current in CPR certification.
Yes
No
Date of expiration on CPR card:
3. As of (date) ___________, the participant meets all criteria to take the LLAM recertification class.
Agency:
Date: ________________
Participants Signature: _____________________________________________________________
Agency Administrator/Designee:
Note:
Please bring a copy of the LLAM course manual, pen/pencil, and Photo
I.D. to class. LLAM manual s are to be provided by employing agency.
03/2018
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