Form NH-10 "Certification of Program Completion for Nursing Home Administrative Intern Program" - New Jersey

What Is Form NH-10?

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

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the New Jersey Department of Health;
  • 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 Form NH-10 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form NH-10 "Certification of Program Completion for Nursing Home Administrative Intern Program" - New Jersey

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New Jersey Department of Health
Nursing Home Administrators Licensing Board
CERTIFICATION OF PROGRAM COMPLETION FOR
NURSING HOME ADMINISTRATIVE INTERN PROGRAM
Mailing Address:
Overnight Services (UPS, FedEx, Airborne):
PO Box 358
25 South Stockton Street, 2nd Floor
Trenton, NJ 08625-0358
Trenton, NJ 08608-1832
INSTRUCTIONS TO PRECEPTOR: At the conclusion of the training program, please complete this form
and forward to the Nursing Home Administrators Licensing Board at either of the two listed addresses.
Name of Applicant
Social Security Number
Name of Preceptor (Must be Licensed Nursing Home Administrator)
License Number
Name of Licensed Long Term Care Facility Training Site
Street Address
City, State, Zip
Telephone Number
Program Start Date
Anticipated Completion Date
/
/
/
/
Hours Completed:
Service Area/Department
Hours
1.
Resident Activities
2.
Administration
3.
Business Office
4.
Dietary
5.
Maintenance
6.
Medical Records
7.
Nursing
8.
Social Services
9.
Environmental (including Housekeeping
and Laundry)
10. Other (Specify):
TOTAL NUMBER OF HOURS IN TRAINING PROGRAM
Comments
(Attach additional sheets if necessary)
I certify that the applicant named above has satisfactorily completed this program under my supervision, and
I recommend that the applicant be allowed to take the Nursing Home Administrator Licensing Examination.
Signature of Preceptor
Date
NH-10
MAY 16
New Jersey Department of Health
Nursing Home Administrators Licensing Board
CERTIFICATION OF PROGRAM COMPLETION FOR
NURSING HOME ADMINISTRATIVE INTERN PROGRAM
Mailing Address:
Overnight Services (UPS, FedEx, Airborne):
PO Box 358
25 South Stockton Street, 2nd Floor
Trenton, NJ 08625-0358
Trenton, NJ 08608-1832
INSTRUCTIONS TO PRECEPTOR: At the conclusion of the training program, please complete this form
and forward to the Nursing Home Administrators Licensing Board at either of the two listed addresses.
Name of Applicant
Social Security Number
Name of Preceptor (Must be Licensed Nursing Home Administrator)
License Number
Name of Licensed Long Term Care Facility Training Site
Street Address
City, State, Zip
Telephone Number
Program Start Date
Anticipated Completion Date
/
/
/
/
Hours Completed:
Service Area/Department
Hours
1.
Resident Activities
2.
Administration
3.
Business Office
4.
Dietary
5.
Maintenance
6.
Medical Records
7.
Nursing
8.
Social Services
9.
Environmental (including Housekeeping
and Laundry)
10. Other (Specify):
TOTAL NUMBER OF HOURS IN TRAINING PROGRAM
Comments
(Attach additional sheets if necessary)
I certify that the applicant named above has satisfactorily completed this program under my supervision, and
I recommend that the applicant be allowed to take the Nursing Home Administrator Licensing Examination.
Signature of Preceptor
Date
NH-10
MAY 16