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On-the-Job Facility Training Plan Application and Updates

On-the-Job Facility Training Plan Application and Updates

Use this form for initial approval to include on-the-job skills hours in the 75-hour long-term care worker basic training. Use this form to submit changes to an approved plan. Submit this application with “OJT” and your facility’s name in the subject line. You must complete this form prior to implementation of OJT skills at your facility.

TRAINING CONTACTS NAME(Required)

Section 1. Core Basic Training

Who will teach the instructional part of Core Basic Training for your facility?(Required)

Section 2. Population Specific Training

Specify which Population Specific classes your long-term care workers will take for certification and list the approved instructor for each class. Population specific training should reflect the needs of your facilities population. We recommend 16 hours total from the following options:
Classes(Required)
Approved Instructor's Name(Required)

Section 3. Orientation and Safety Training

Specify how your long-term care workers will take Orientation and Safety classes(Required)

Section 4. 75-hour HCA Certification Plan

Please specify your facility’s training plan:
75-hour HCA Certification Plan(Required)
Total: 75 Hours

Section 5. Submit completed Facility Training application to TrainingApprovalTPA@dshs.wa.gov with “OJT” and your facility’s name in the subject line. You must complete this form prior to initiation of OJT skills instruction.

WA-
MM slash DD slash YYYY
PRINT INSTRUCTOR NAME(Required)
This field is for validation purposes and should be left unchanged.

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