Application

Facility Instructor Application

For Adult Family Homes, Assisted Living Facilities, and Enhanced Services Facilities Submit this form to offer Core Basic Training, Dementia Specialty Training, Mental Health Specialty Training, Developmental Disabilities, and/or Expanded Specialty Training (Traumatic Brain Injury Specialty and Diabetes Specialty). The instructor must sign this form. WAC 388-112A-1240

Section 1. General Information and Qualifications

INSTRUCTORS NAME(Required)
MM slash DD slash YYYY
FACILITY’S NAME(Required)
1. Are you 21 years old or older?(Required)
2. Are you an owner or administrator of an adult family home, assisted living facility, enhanced services facility, nursing home, home care agency, or supported living in Washington?(Required)
If yes, please list the type of license and the license number (supported living providers list the type of certification and certification number). If no, leave blank.
Type of license or certification
3. Are you a health care or service professional, such as an HCA, NAC, LPN, RN, or ARNP?(Required)
If yes, please list any licenses or certifications you hold in Washington. If no, leave blank.
Type of license or certification
You are a registered nurse with work experience within the last five years with the elderly or persons with disabilities requiring long-term care in a community setting(Required)
If yes, license or certification
MM slash DD slash YYYY

Section 2. Education and Work Experience (select highest level of experience)

You are a registered nurse with work experience within the last five years with the elderly or persons with disabilities requiring long-term care in a community setting(Required)
You have an associate degree or higher degree in the field of health or human services and six months professional or caregiving experience within the last five years in a community based setting such as an adult family home, or assisted living facility.(Required)
You have a high school diploma, or equivalent, and one year of professional or caregiving experience within the last five years in a community based setting such as an adult family home, assisted living facility, supported living through DDA, or home care setting(Required)

Section 3. Teaching Experience (select highest level of experience)

You have 100 hours of experience teaching adults on topics directly related to the basic training.(Required)
You have 40 hours of teaching basic training while being mentored by an instructor who is approved to teach basic training(Required)
I have the ability to list three ways for improving your instructional facilitation and the method the instructor will use to measure improvement such as submitting the continuous improvement plan feedback from the DSHS adult education class(Required)
Instructors with adult family homes, enhanced services facilities, and assisted living facilities that do not meet a teaching criteria above must have and attest to the following experience to be approved to teach their own staff: I have 40 hours of informal teaching experiences unrelated to basic training topics such as guest lecturing, team teaching, and volunteer teaching with parks, local high schools, 4-H groups, English as a Second Language (ESL) groups, senior organizations, and religious organization AND I have the ability to implement three adult learning techniques in your long-term care worker training, AND I have the ability to list three ways for improving your instructional facilitation and the method the instructor will use to measure improvement such as submitting the continuous improvement plan feedback from the DSHS adult education class

Section 4. Additional Training and Caregiving Experience (select all that apply)

You have 1) attended an adult education class, 2) attended the Specialty Training class(es) you are requesting to teach, and 3) have attached your certificates of completion to this application.(Required)
You have experience or training in conducting assessments and competency testing(Required)
You are experienced in caregiving practices and capable of demonstrating competency with respect to teaching the course content or units being taught(Required)

Section 5. Certification and Attestation

Attestation
Name
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This field is for validation purposes and should be left unchanged.