"Application for Reinstatement - Kansas Adult Care Home Administrator License" - Kansas

Application for Reinstatement - Kansas Adult Care Home Administrator License is a legal document that was released by the Kansas Department for Aging and Disability Services - a government authority operating within Kansas.

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Board of Adult Care Home Administrators
Application for Reinstatement
Kansas Adult Care Home Administrator License
A Kansas adult care home administrator license may be reinstated upon meeting requirements of K.S.A. 65-
3503(d) and K.A.R. 28-38-23. Please complete this application documenting at least 50 clock hours of continuing
education, with a minimum of 10 hours is in resident care and 30 hours in administration, and return it with
completed Information Inventory, proof of your social security number, and appropriate reinstatement and renewal
fees.
License #____________________
Social Security Number____________________________________
Name
Other name used
Address_____________________________________________________________________________________
City________________________________________ State___________________ Zip_____________________
Phone:
Work (_____)_______________________
Home(_____)_______________________________
RECORD OF CONTINUING EDUCATION CLOCK HOURS
Clock hours submitted for the purpose of reinstatement shall be earned within the licensure period immediately
preceding application for reinstatement.
PRIOR APPROVED PROGRAMS: record approval number, title, date and hours. You must submit verification
of attendance for all prior approved programs listed.
PROGRAMS NOT PRIOR APPROVED: record title, date and hours below. You must submit 1) course content,
2) objectives, 3) time frame of educational activity and 4) verification of attendance.. (Note - hours exclude time
allotted for regulations, breaks, lunch, business meetings, etc. Credit for full hour or half hour only)
Approval
Program Title
Date
Resident
Administration
Electives
Number
Care
10 hours
30 hours
maximum
minimum
minimum
10 hours
(Please complete the remainder of the application on the back of this page.)
Board of Adult Care Home Administrators
Application for Reinstatement
Kansas Adult Care Home Administrator License
A Kansas adult care home administrator license may be reinstated upon meeting requirements of K.S.A. 65-
3503(d) and K.A.R. 28-38-23. Please complete this application documenting at least 50 clock hours of continuing
education, with a minimum of 10 hours is in resident care and 30 hours in administration, and return it with
completed Information Inventory, proof of your social security number, and appropriate reinstatement and renewal
fees.
License #____________________
Social Security Number____________________________________
Name
Other name used
Address_____________________________________________________________________________________
City________________________________________ State___________________ Zip_____________________
Phone:
Work (_____)_______________________
Home(_____)_______________________________
RECORD OF CONTINUING EDUCATION CLOCK HOURS
Clock hours submitted for the purpose of reinstatement shall be earned within the licensure period immediately
preceding application for reinstatement.
PRIOR APPROVED PROGRAMS: record approval number, title, date and hours. You must submit verification
of attendance for all prior approved programs listed.
PROGRAMS NOT PRIOR APPROVED: record title, date and hours below. You must submit 1) course content,
2) objectives, 3) time frame of educational activity and 4) verification of attendance.. (Note - hours exclude time
allotted for regulations, breaks, lunch, business meetings, etc. Credit for full hour or half hour only)
Approval
Program Title
Date
Resident
Administration
Electives
Number
Care
10 hours
30 hours
maximum
minimum
minimum
10 hours
(Please complete the remainder of the application on the back of this page.)
License in Another State
List all states in which you have ever held an adult care home administrator license since obtaining your Kansas
license:
State: ____________________
State: ___________________
State: ____________________
State: ____________________
State: ___________________
State: ____________________
For each state, complete Part I of the Verification of License form, request that state’s board complete Part II and
return verification to the Kansas board.
Disciplinary Action - This information is required under Kansas law: KSA 65-3503(a)
Has any license, certification, or registration issued by Kansas or another state or entity been denied, refused for
renewal, suspended, revoked or subjected to any other disciplinary action? Y / N
If YES, please explain:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
__________________________________________________________________________________
Have you ever been convicted of a crime by any court (including Kansas), or any federal court of the United
States? Y / N . If YES, please indicate:
Date of conviction:____________________________________________________________________________
Crime of which convicted:_______________________________________________________________________
I do hereby attest that the information supplied in this application and any attachment is accurate and complete
to the best of my knowledge. I do hereby give permission to the board to verify any information provided in this
application and attachments. I understand that the application fee is non-refundable should I not meet licensure
qualifications.
Signature:_____________________________________________ Date:_____________________________
L L L L
PLEASE NOTE: YOUR SIGNATURE MUST BE NOTARIZED
SUBSCRIBED AND SWORN TO before me, the undersigned authority,
on this____________ day of_______________________, 20________
_________________________________________________________
(Notary Public)
My appointment expires:______________________________________
Submit application, fee and supporting documents to:
Health Occupations Credentialing
Kansas Department
Topeka KS 666
:
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