DOEA Form ALF/ADRD-002 "Alzheimer's Disease and Related Disorders Training Three-Year Curriculum Certification" - Florida

What Is DOEA Form ALF/ADRD-002?

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

Form Details:

  • Released on November 1, 2013;
  • The latest edition provided by the Florida Department of Elder Affairs;
  • 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 printable version of DOEA Form ALF/ADRD-002 by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

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Download DOEA Form ALF/ADRD-002 "Alzheimer's Disease and Related Disorders Training Three-Year Curriculum Certification" - Florida

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ASSISTED LIVING FACILITY
Alzheimer’s Disease And Related Disorders Training Three-Year
Curriculum Certification
(Incorporated by reference in rule 58A-5.0194, F.A.C., pursuant to s. 429.178, F.S.)
:
For agency use only
Special instructions
Please read this application
carefully. Fill in all the blanks. Return the com-
Approved
Not Approved
Preapproval
Date
Date
pleted application along with your curriculum to:
Training Academy on Aging
_______
_______
School of Aging Studies
13301 Bruce B. Downs Blvd.
FMHI – MHC 1300
_______
_______
Tampa, FL 33612
Curriculum # __________
Approval # ___________
(813) 974-3414
Part 1: Applicant Contact Information:
(The information provided below will be used for all future correspondence)
Name: ______________________________________________________________
Company (if applicable): ________________________________________________
Address: ____________________________________________________________
Apt #
____________________________________________________________
City
State
Zip code
County
Telephone: (_____)_________________________________________________
Area code
Number
Fax: (_____)________________________________________________________
Area code
Number
E-Mail: ______________________________________________________________
Part 2: Application Certification
I hereby affirm that all information included in this application is true and correct.
Print or type name of applicant: ___________________________________________
Signature of applicant: __________________________________________________
Date: _________________
DOEA ALF/ADRD-002 (November 2013)
58A-5.0194
1
ASSISTED LIVING FACILITY
Alzheimer’s Disease And Related Disorders Training Three-Year
Curriculum Certification
(Incorporated by reference in rule 58A-5.0194, F.A.C., pursuant to s. 429.178, F.S.)
:
For agency use only
Special instructions
Please read this application
carefully. Fill in all the blanks. Return the com-
Approved
Not Approved
Preapproval
Date
Date
pleted application along with your curriculum to:
Training Academy on Aging
_______
_______
School of Aging Studies
13301 Bruce B. Downs Blvd.
FMHI – MHC 1300
_______
_______
Tampa, FL 33612
Curriculum # __________
Approval # ___________
(813) 974-3414
Part 1: Applicant Contact Information:
(The information provided below will be used for all future correspondence)
Name: ______________________________________________________________
Company (if applicable): ________________________________________________
Address: ____________________________________________________________
Apt #
____________________________________________________________
City
State
Zip code
County
Telephone: (_____)_________________________________________________
Area code
Number
Fax: (_____)________________________________________________________
Area code
Number
E-Mail: ______________________________________________________________
Part 2: Application Certification
I hereby affirm that all information included in this application is true and correct.
Print or type name of applicant: ___________________________________________
Signature of applicant: __________________________________________________
Date: _________________
DOEA ALF/ADRD-002 (November 2013)
58A-5.0194
1
THREE-YEAR CURRICULUM CERTIFICATION
For Alzheimer’s Disease and Related Disorders
Level I (4-Hour) and Level II (4-Hour) Training
Part 3: Training Curriculum Requirements
For Level I (Four-Hour) Alzheimer’s Disease and Related Disorders
To obtain approval for the 4-hour Alzheimer’s Disease and Related Disorders training
curriculum certification, you must submit a training curriculum that addresses the
following subject areas:
1. Understanding Alzheimer’s disease and related disorders;
2. Characteristics of Alzheimer’s disease;
3. Communicating with residents with Alzheimer’s disease;
4. Family issues;
5. Resident environment; and
6. Ethical issues.
For Level II (Four-Hour) Alzheimer’s Disease and Related Disorders
To obtain approval for the 4-hour Alzheimer’s Disease and Related Disorders training
curriculum certification, you must submit a training curriculum that addresses the
following subject areas:
1. Behavior management;
2. Assistance with ADLs;
3. Activities for residents;
4. Stress management for the care giver; and
5. Medical information.
IMPORTANT INFORMATION/INSTRUCTIONS:
Please send your completed application along with:
A hard copy of your Training Curriculum Outline and Content;
Hard copies of any Training Curriculum Handouts, Videos, CDs, and;
Any other curriculum materials to be used for any other purposes such as
teleconferencing, Internet web pages, etc.
No application will be accepted without complete the curriculum.
Upon receipt of your application and curriculum, it will be reviewed and you will be sent
written notification of the status of your application. Curriculum approval is limited to
three (3) years from the date of approval.
Please note: ANY MATERIALS SUBMITTED WITH THIS APPLICATION WILL NOT BE
RETURNED.
DOEA ALF/ADRD-002 (November 2013)
58A-5.0194
2
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