DOEA Form HH/ADRD-001 "Application for Home Health Care Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida

Form HH/ADRD-001 or the "Application For Home Health Care Training Provider Certification - Alzheimer's Disease Or Related Disorders Training" is a form issued by the Florida Department of Elder Affairs.

The form was last revised in May 1, 2005 and is available for digital filing. Download an up-to-date Form HH/ADRD-001 in PDF-format down below or look it up on the Florida Department of Elder Affairs Forms website.

ADVERTISEMENT

Download DOEA Form HH/ADRD-001 "Application for Home Health Care Training Provider Certification - Alzheimer's Disease or Related Disorders Training" - Florida

1407 times
Rate
(4.6 / 5) 98 votes
APPLICATION FOR
HOME HEALTH CARE TRAINING PROVIDER CERTIFICATION
ALZHEIMER’S DISEASE OR RELATED DISORDERS TRAINING
Incorporated by reference in rule 58A-8.001 and 58A-8.002, FAC, pursuant to s. 400.4785(1)(f) 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
Need More Information
Training Academy on Aging
Other
School of Aging Studies
Approved
University of South Florida
Comments
13301 Bruce B. Downs Blvd.
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
HOME HEALTH CARE TRAINING PROVIDER CERTIFICATION
ALZHEIMER’S DISEASE OR RELATED DISORDERS TRAINING
Incorporated by reference in rule 58A-8.001 and 58A-8.002, FAC, pursuant to s. 400.4785(1)(f) 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
Need More Information
Training Academy on Aging
Other
School of Aging Studies
Approved
University of South Florida
Comments
13301 Bruce B. Downs Blvd.
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 and Related Disorders Training
(Incorporated by reference in Rule 58A-8.002(1)(a), FAC, pursuant to s. 400.4785(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):
o A Bachelor’s degree in a health-care, human service or
gerontology related field from an accredited college or
university (see substitutions below), or
o Licensure as a registered nurse.
In addition to the above requirements, you must provide proof of one of the
following criteria:
o Possess 1 year of teaching or training experience as an educator of
care givers for persons with Alzheimer’s Disease and Related
Disorders; or
o Have one (1) year of practical experience in a program providing
care to persons with Alzheimer’s Disease and Related Disorders; or
o Have completed a specialized training program of 4 hours or more
in Alzheimer’s Disease and Related Disorders from a university or
an accredited health care or human service or gerontology
continuing education provider.
Substitutions:
o 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
o 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 HH/ADRD-001 (May 2005)
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:
o Copy of your final official transcripts of Baccalaureate degree in a
health-care, human service or gerontology related field.
o Copy of your current license as a registered nurse.
o Letter from employer (on company letterhead) noting starting and ending
dates of service and types of services provided to persons with
Alzheimer’s Disease and Related Disorders.
o Documentation of successful completion of approved university
based coursework in caring for persons with Alzheimer’s Disease
and Related Disorders.
o Certificate/s of successful completion of specialized training program/s in
caring for persons with Alzheimer’s Disease and Related Disorders from
a university or an accredited health care or human service or
gerontology continuing education provider.
o Documentation of successful completion of CEU approved
presentations, workshops, or seminars in caring for persons with
Alzheimer’s Disease and Related Disorders.
o Copy of your final official transcripts of Master’s degree in a health
related field.
o Documentation of successful completion of training and
continuing education consistent with the requirements of section
400.4178, or completion of training consistent with the
requirements of sections 400.1755, 400.5571 or 400.6045, Florida
Statutes.
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-8.001, (1), FAC.
Please note: ANY MATERIALS SUBMITTED WITH THIS APPLICATION CANNOT BE
RETURNED.
DOEA Form HH/ADRD-001 (May 2005)
3
ADVERTISEMENT
Page of 3