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Adult Family Home Training Network Worker Sponsorship Pilot Program


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Adult Family Home Training Network Worker Sponsorship Pilot Program

Adult Family Home Sponsorship Application

Updated 2/25/22

The cost of the training and—for certain specified training—employee salary and benefits during the training, will be paid by The Long-Term Care Foundation from a portion of the training benefit negotiated for Adult Family Homes in the collective bargaining agreement with the State of Washington.

Information collected from this application will be part of a data analysis of the pilot program.

Adult Family Home

 

Address:

 

Is your adult family home approved to offer on-the-job training  If Yes, what type of training:  

 

 Do you currently have a Medicaid contract?   

How many Medicaid clients do you have?  

 

Do you have an applicant that you would like to sponsor through one or more qualifying training?  

Sponsored Applicant:

First Name: Last Name:  

Address: City:

State: Zip Code: County:  

Telephone: Email:  

 

Date of Birth (MM/DD/YYYY): Hire Date/Intend to Hire Date:

Gender (Chose one): Race (Check one):  

Disability: Military Veteran:  

 

Does the applicant have previous health care experience?:

If yes, please describe:  

 

Does the applicant currently hold any certifications?   If yes, please describe:  

 

Please check off what the applicant has completed below to work in Adult Family Home:

Background Check: Food Handlers:  

CPR/First Aid: TB test completed:  

 

Which of the trainings below are needed for applicant to become a long-term care worker?

Home Care Aide Training (75 hours) & Testing:        

Mental Health Specialty Training:  Dementia Specialty Training:  

HCA Pre-Prometric Test Refresher:  

Nurse Delegation:  Nurse Delegation—Diabetes:  

 

 

Which of the following DSHS-approved training companies will you choose to provide the training you require?

 

Community Colleges of Spokane (offers Adult Education, AFH Administrator, HCA/CNA Bridge, HIV/AIDs, HCA, HCA Skills Refresher)

Cornerstone Healthcare Training Company, LLC (offers Dementia, HIV/AIDs, HCA, Mental Health, Nurse Delegation, Nurse Delegation Diabetes)

Long-Term Care Education Associates (offers Dementia, Mental Health, Nurse Delegation, Nurse Delegation Diabetes)

Headway Nursing Services (offers Dementia, HIV/AIDs, HCA, Mental Health, Nurse Delegation, Nurse Delegation Diabetes, Adult Education)

Northcare Training (offers Dementia, HCA, HCA/CNA Bridge, Mental Health, Nurse Delegation, Nurse Delegation Diabetes)

S&H Training Center, Inc. (offers Dementia, HCA, Mental Health, Nurse Delegation, Nurse Delegation Diabetes)

Washington Care Academy, LLC (offers Dementia, HCA, Mental Health, Nurse Delegation, Nurse Delegation Diabetes)

Other:

For those choosing CNA training, please visit https://www.doh.wa.gov/LicensesPermitsandCertificates/ NursingCommission/NursingEducation/ NursingAssistantCertified/ProgramList, pick your top three choices, and add them below

1)

2)

3)

 

Is the applicant able to take the training online?:  

How soon can the applicant begin the training?

 

Applicant's Highest Grade Completed:  

 

How did you hear about us?  

Referral (who referred you):  

 

 

Adult Family Home Contact’s Signature:                                                                                                                               

 

 

Sponsored Applicant's Signature:                                                                                                                             

 

 

Program Eligibility Criteria (LTCF Use Only)
Medicaid Contract
Number of Medicaid clients
Has applicant completed HS/GED
Background Check
Is applicant committed to taking requested training
Training needed to complete requirements for certification
Applicant able to take requested training online
Applicant able/willing to use DSHS approved trainer
TB Test
CPR/First Aid
Food Handlers

Leave this empty:

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Signature Certificate
Document name: Adult Family Home Training Network Worker Sponsorship Pilot Program
lock iconUnique Document ID: f3aa6a2a3fd0613cfc6c964d5672486728bc0be8
Timestamp Audit
June 5, 2022 8:07 pm PDTAdult Family Home Training Network Worker Sponsorship Pilot Program Uploaded by Faduma Mursal ( Director of Training Washington Care Academy) - [email protected] IP 73.225.24.78