Facility Training Program Application and Updates

Section 1. Facility Training Program Information

TRAINING COORDINATORS NAME(Required)

First Last

DATE

PHONE NUMBER (AREA CODE)

CELL NUMBER (AREA CODE)

EMAIL ADDRESS(Required)

APPLICATION TYPE (CHECK ALL THAT APPLY)(Required)

New facility training program

Updating an Approved facility training program

Adding and/or removing instructor

TRAINING PROGRAM NAME

If this is a new training program, please leave Training Program Name and Number blank.

TRAINING PROGRAM NUMBER

If this is a new training program, please leave Training Program Name and Number blank.

FACILITY NAME(Required)

LICENSE NUMBER(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code

EMAIL ADDRESS(Required)

PHONE NUMBER (AREA CODE)(Required)

WEBSITE ADDRES

FAX NUMBER (AREA CODE)

Section 2. Course Information

Course(Required)

Core Basic Skills OJT

16 hours Core Basic Skills On the Job Training (OJT)

Section 3. Instructor Information/Changes

Instructors applying to teach Core Basic, Dementia Specialty, Mental Health Specialty, Developmental Disabilities, and/or Expanded Specialty Training (Traumatic Brain Injury Specialty and Diabetes Specialty) must submit copies of their specialty training certificates, if applicable, and Adult Education certificates with their Facility Instructor Application (DSHS 15-554).

Name(Required)

First Last

INSTRUCTOR STATUS(Required)

Add New Instructor

DSHS approved but adding new course(s)

Remove, no longer teaching

CHECK ALL COURSES THAT APPLY(Required)

Core Basic Skills OJT (16 hours OJT)

BIRTHDAY (MM/DD/YYYY)(Required)

Section 4. Instructor Attestation for Orientation, Safety, and CE Instructors.

Read and complete the attestation below. By filling in your name, job title, and date below, you attest that you: • Have verified all instructors meet the Facility Instruction Qualification Requirements (DSHS 22-1855). • Have on file the verifying information for each instructor. • Have submitted true, complete, and accurate information.

NAME

First Last

JOB TITLE

DATE

Section 5. Is your application complete?

Did you remember to attach

Copies of your Specialty Training and Adult Education Certificates of completion, if requred.

If you are submitting curriculum you developed, attach the required form with your application.

For Orientation and Safety, Population Specific Training, and Continuing Education, submit the Curriculum Approval Application (DSHS 15-552).

Email your questions and submit your application to TrainingApprovalTPA@dshs.wa.gov. For more information about long-term care worker training, please visit the DSHS Training Requirements and Classes page.

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