DOEA Form ADC/ADRD-001 "Application for Adult Day Care Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida

Form ADC/ADRD-001 is a Florida Department of Elder Affairs form also known as the "Application For Adult Day Care Training Provider Certification - Alzheimer's Disease Or Related Disorders Training". The latest edition of the form was released in September 1, 2003 and is available for digital filing.

Download a PDF version of the Form ADC/ADRD-001 down below or find it on Florida Department of Elder Affairs Forms website.

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Download DOEA Form ADC/ADRD-001 "Application for Adult Day Care Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida

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APPLICATION FOR
ADULT DAY CARE TRAINING PROVIDER CERTIFICATION
ALZHEIMER’S DISEASE OR RELATED DISORDERS TRAINING
Incorporated by reference in rule 58A-6.015 and 58A-6.016, FAC, pursuant to s. 429.917(1) F.S.
FOR AGENCY USE ONLY:
SPECIAL INSTRUCTIONS: Please read this application carefully and fill in all
ID#
Date
of the blanks. Return the completed application along with written proof of
Type:
your eligibility to:
Received
Acknowledged
By Regular or Express Mail:
Incomplete
Training Academy on Aging
Need More Information
School of Aging Studies
Other
University of South Florida
Approved
13301 Bruce B. Downs Blvd.,
Comments
FMHI - MHC 1300
Tampa, FL 33612
PART 1—APPLICANT CONTACT INFORMATION:
The information provided below is public record and reflects ownership of submitted materials.
Name:
Company Name (if applicable):
Address:
City
State
Zip Code
County
Telephone:
Fax:
E-Mail:
(
)
(
)
Part 2: Application Affidavit
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 Form ADRD-002 (November 2001)
1
APPLICATION FOR
ADULT DAY CARE TRAINING PROVIDER CERTIFICATION
ALZHEIMER’S DISEASE OR RELATED DISORDERS TRAINING
Incorporated by reference in rule 58A-6.015 and 58A-6.016, FAC, pursuant to s. 429.917(1) F.S.
FOR AGENCY USE ONLY:
SPECIAL INSTRUCTIONS: Please read this application carefully and fill in all
ID#
Date
of the blanks. Return the completed application along with written proof of
Type:
your eligibility to:
Received
Acknowledged
By Regular or Express Mail:
Incomplete
Training Academy on Aging
Need More Information
School of Aging Studies
Other
University of South Florida
Approved
13301 Bruce B. Downs Blvd.,
Comments
FMHI - MHC 1300
Tampa, FL 33612
PART 1—APPLICANT CONTACT INFORMATION:
The information provided below is public record and reflects ownership of submitted materials.
Name:
Company Name (if applicable):
Address:
City
State
Zip Code
County
Telephone:
Fax:
E-Mail:
(
)
(
)
Part 2: Application Affidavit
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 Form ADRD-002 (November 2001)
1
APPLICANT CREDENTIALS
For Alzheimer’s Disease or Related Disorders Training
(Incorporated by reference in Rules 58A-6.015 and 58A-6.016, FAC, pursuant to s. 400.5571(1), F.S.)
Part 3 - Applicant Credentialing Requirements Checklist
In order to be eligible for certification, you must provide proof of one the
following (see substitutions and exceptions below):
A Bachelor’s degree in a health-care, human service or gerontology
related field from an accredited college or university (see
substitutions below), or
Licensure as a registered nurse.
In addition to the above requirements, you must provide proof of one of the
following criteria:
Possess 1 year of teaching or training experience as an educator of care
givers for persons with Alzheimer’s Disease or Related Disorders; or
Have one (1) year of practical experience in a program providing care
to persons with Alzheimer’s Disease or Related Disorders; or
Have completed a specialized training program (total of 4 hours or
more) in Alzheimer’s Disease or Related Disorders from a university or
an accredited health care or human service or gerontology continuing
education provider.
Substitutions:
A Master’s degree in a health-care, human service or gerontology related
field from an accredited college or university may substitute for the
teaching or training experience. or
Proof of Teaching or training experience as an educator of caregivers for
persons with Alzheimer’s Disease or Related Disorders may substitute on
a year-by-year basis for the required Bachelor’s degree/nursing license.
DOEA Form ADC/ADRD-001 (September 2003)
2
Part 4 – Applicant Documentation Checklist
The following documents may be used as written proof of your eligibility and must
be enclosed with your application:
Copy of your final official transcripts of Baccalaureate degree in a health-care,
human service or gerontology related field.
Copy of your current license as a registered nurse.
Letter from employer (on company letterhead) noting starting and ending dates
of service and types of services provided to persons with Alzheimer’s Disease or
Related Disorders.
Documentation of successful completion of approved university based coursework
in caring for persons with Alzheimer’s Disease or Related Disorders.
Certificate/s of successful completion of specialized training program/s in caring
for persons with Alzheimer’s disease or Related Disorders from a university or an
accredited health care or human service or gerontology continuing education
provider.
Documentation of successful completion of CEU approved presentations, workshops,
or seminars in caring for persons with Alzheimer’s Disease or Related Disorders.
Copy of your final official transcripts of Master’s degree in a health related field.
IMPORTANT INFORMATION/INSTRUCTIONS:
Please send this application along with written proof of eligibility (see above,
documentation checklist) to the address on the front of this application. No application
will be accepted without written proof of eligibility.
Within thirty (30) calendar days from the date your application is received, your
credentials will be reviewed and you will be sent written notification of the status of your
application.
You must be an approved training provider and utilize an approved training curriculum
prior to commencing training activities, pursuant to rule 58A-6.015 and 58A-6.016, (1),
FAC.
Please note: ANY MATERIALS SUBMITTED WITH THIS APPLICATION CANNOT BE
RETURNED.
DOEA Form ADC/ADRD-001 (September 2003)
3
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