DOEA Form ALF/ADRD-001 "Alzheimer's Disease and Related Disorders Training Provider Certification" - Florida

What Is DOEA Form ALF/ADRD-001?

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-001 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-001 "Alzheimer's Disease and Related Disorders Training Provider Certification" - Florida

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ASSISTED LIVING FACILITY
Alzheimer’s Disease And Related Disorders Training Provider
Certification
(Incorporated by reference in rule 58A-5.0194, 58T-1.205, F.A.C., pursuant to s. 429.178, F.S.)
Special instructions
For agency use only
: Please read this
application carefully. Fill in all the blanks.
Approved
Not Approved
Preapproval
Date
Date
Return the completed application along with
written proof of your eligibility to:
_______
_______
Training Academy on Aging
School of Aging Studies
13301 Bruce B. Downs Blvd.
FMHI – MHC 1300
_______
_______
Tampa, Florida 33612
Trainer #
__________
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: Applicant 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-001 (November 2013)
58A-5.0194, 58T-1.205
1
ASSISTED LIVING FACILITY
Alzheimer’s Disease And Related Disorders Training Provider
Certification
(Incorporated by reference in rule 58A-5.0194, 58T-1.205, F.A.C., pursuant to s. 429.178, F.S.)
Special instructions
For agency use only
: Please read this
application carefully. Fill in all the blanks.
Approved
Not Approved
Preapproval
Date
Date
Return the completed application along with
written proof of your eligibility to:
_______
_______
Training Academy on Aging
School of Aging Studies
13301 Bruce B. Downs Blvd.
FMHI – MHC 1300
_______
_______
Tampa, Florida 33612
Trainer #
__________
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: Applicant 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-001 (November 2013)
58A-5.0194, 58T-1.205
1
APPLICANT CREDENTIALS
For Alzheimer’s Disease and Related Disorders Training
Part 3 - Applicant Credentialing Requirements Checklist
In order to be eligible for certification, you must provide proof of one the
following:
A Master’s degree from an accredited college or university in a health
care, human service, or gerontology-related field;
OR
A Bachelor’s degree from an accredited college or university, or licensure
as a registered nurse, AND one of the following:
o Proof of 1 year of teaching experience as an educator of caregivers
for individuals with Alzheimer’s disease or related disorders; OR
o Proof of completion of a specialized training program specifically
relating to Alzheimer’s disease or related disorders, and a minimum
of 2 years of practical experience in a program providing direct care
to individuals with Alzheimer’s disease or related disorders; OR
o Proof of 3 years of practical experience in a program providing direct
care to persons with Alzheimer’s disease or related disorders.
DOEA ALF/ADRD-001 (November 2013)
58A-5.0194, 58T-1.205
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 a Baccalaureate degree from an accredited
college or university.
 Copy of your current license as a registered nurse.
 Letter from employer (on company letterhead) noting starting and ending dates
of teaching experience as an educator of caregivers for persons with Alzheimer’s
disease or related disorders for a minimum of one year.
 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 for a minimum of three years.
 Documentation of successful completion of a specialized training program in
Alzheimer’s disease or related disorders and a 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 for a minimum
of two years.
 Documentation of successful completion of CEU 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 from an accredited college
or university in a subject area related to Alzheimer’s disease or related disorders.
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.
Upon receipt of your application, 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-5.0194, F.A.C.
Please note: ANY MATERIALS SUBMITTED WITH THIS APPLICATION WILL NOT BE
RETURNED.
DOEA ALF/ADRD-001 (November 2013)
58A-5.0194, 58T-1.205
3
Part 5 – Training Course Curriculum Checklist
 I am submitting my Training Course Curriculum for approval with this application.
(Note: if checked, a completed “Application for Alzheimer’s Disease or
Related Disorders Training Curriculum Certification” must accompany this
application).
 The Training Course Curriculum/Curricula I will be using has/have been
submitted and approved.
Curriculum Approval #_________
Submitted by (Name)
______________________________
Company (if applicable)
______________________________
Address
______________________________
City, State, Zip
______________________________
Date Submitted
______________________________
 The Training Course Curriculum I will be using has been submitted and approval
is pending.
Submitted by (Name) ______________________________
Company (if applicable)
______________________________
Address
______________________________
City, State, Zip
______________________________
Date Submitted
______________________________
 The Training Course Curriculum I will be using has not been submitted. Note:
This application will be held pending submittal and approval of Training Course
Curriculum:
To be submitted by (Name) ______________________________
Company (if applicable)
______________________________
Address
______________________________
City, State, Zip
______________________________
Date to be Submitted
______________________________
NOTICES
1.
If your Training Course Curriculum has not been approved, your application for
approval will be held until your Training Course Curriculum receives approval.
2.
All requests to use copyrighted Training Course Curriculum materials must be
accompanied by permission from the author for use.
DOEA ALF/ADRD-001 (November 2013)
58A-5.0194, 58T-1.205
4
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