DOEA Form Hospice/ADRD-002 "Application for Hospice Three-Year Curriculum Certification - Alzheimer's Disease or Related Disorders Training" - Florida

What Is DOEA Form Hospice/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 September 1, 2003;
  • 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 Hospice/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 Hospice/ADRD-002 "Application for Hospice Three-Year Curriculum Certification - Alzheimer's Disease or Related Disorders Training" - Florida

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APPLICATION FOR
HOSPICE THREE-YEAR CURRICULUM CERTIFICATION
ALZHEIMER’S DISEASE OR RELATED DISORDERS TRAINING
Incorporated by reference in rule 58A-2.027 and 58A-2.028, FAC, pursuant to s. 400.6045(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:
Apt. #
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 Hospice/ADRD-002 (September 2003)
1
APPLICATION FOR
HOSPICE THREE-YEAR CURRICULUM CERTIFICATION
ALZHEIMER’S DISEASE OR RELATED DISORDERS TRAINING
Incorporated by reference in rule 58A-2.027 and 58A-2.028, FAC, pursuant to s. 400.6045(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:
Apt. #
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 Hospice/ADRD-002 (September 2003)
1
THREE-YEAR CURRICULUM CERTIFICATION
For Alzheimer’s Disease or Related Disorders
1-Hour and 3-Hour Training
(Incorporated by reference in Rules 58A-2.027 and 58A-2.028, FAC, pursuant to s. 400.6045(1), F.S.)
Part 3: Training Curriculum Requirements
For One-Hour Alzheimer’s Disease or Related Disorders
To obtain approval for the 1-hour Alzheimer’s Disease or Related Disorders training
curriculum certification, you must submit a training curriculum that addresses the
following subject areas:
Understanding Alzheimer’s Disease or Related Disorders;
1.
Characteristics of Alzheimer’s Disease or Related Disorders;
2.
Communicating with Patients with Alzheimer’s Disease or Related Disorders.
3.
For Three-Hour Alzheimer’s Disease or Related Disorders
To obtain approval for the 3-hour Alzheimer’s Disease or Related Disorders training
curriculum certification, you must submit a training curriculum that addresses the
following subject areas:
1.
Behavior Management;
2.
Assistance with Activities of Daily Life;
3.
Activities for Patients;
4.
Stress Management for the Caregiver;
5.
Family Issues;
6.
Patient Environment; and
7.
Ethical Issues.
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 curriculum.
Within thirty (30) calendar days from the date your application is received your
curriculum 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 date of approval.
Please note: ANY MATERIALS SUBMITTED WITH THIS APPLICATION CANNOT BE
RETURNED.
Special Note: When submitting an application for certification of the 1-hour and 3-hour Alzheimer’s
disease or related disorders training curriculum, it may be helpful to review the “Training Guidelines for
the Special Care of Hospice Patients with Alzheimer’s Disease or Related Disorders” incorporated by
reference into Rule 58A-2.027, FAC.
DOEA Form Hospice/ADRD-002 (September 2003)
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