Cdph Dsd Application Form PDF Details

Navigating the complexities of applying for a Director of Staff Development (DSD) or Instructor position within the healthcare sector in California involves submitting a comprehensive application to the California Department of Public Health (CDPH). This vital document, formally titled the DSD/Instructor Application, is designed to streamline the certification process for professionals aiming to offer training programs in healthcare facilities, schools, or agencies. Applicants are required to submit detailed information, including personal identification, employment history, educational background, and specifics about the training they plan to conduct—ranging from orientation and in-service programs to complete certification training programs. The form also demands evidence of a registered nurse or licensed vocational nurse credential, supplemented by proof of completion of a 24-hour Board of Registered Nursing (BRN) approved DSD class or relevant college course transcripts. Additional prerequisites include a current nursing license and an exhaustive resume that outlines the applicant's work experience, consolidating the application's foundation to meet stringent state and federal instructor requirements. Failure to provide a thorough packet of information will result in the non-approval of the application, underscoring the form’s importance in certifying qualified professionals to develop and lead health education programs across California.

QuestionAnswer
Form NameCdph Dsd Application Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdsd application form, cdph 279, cdph270, dsd application form 2019

Form Preview Example

State of California- Health and Human Services Agency

California Department of Public Health (CDPH)

 

Licensing and Certification Program (L&C)

 

Aide and Technician Certification Section (ATCS)

 

MS 3301, P.O. Box 997416

 

Sacramento, CA 95899-7416

PHONE: (916) 327-2445

FAX: (916) 324-0901 EMAIL: cna@cdph.ca.gov

DIRECTOR OF STAFF DEVELOPMENT (DSD) / INSTRUCTOR

APPLICATION

TYPE OR PRINT LEGIBLY

Facility/School/Agency Telephone Number

County

Provider Identification Training Number (“S” or “F” Number)

Facility / School / Agency Name and Address:

Type of Training to be Offered:

Orientation and In-Service Training Programs Only

Certification Training Program Only

Orientation, In-Service, and Certification Training Programs

Applicant’s Name

 

Registered Nurse (RN)

California Nursing License Number

Expiration Date

 

 

Licensed Vocational Nurse

 

 

 

 

 

 

 

Hours Employed

 

Date Employed as DSD / Instructor

Facility Licensed Bed Capacity

Date Submitted to CDPH

 

 

 

(if applicable)

 

________ per week

_________ per month

 

 

 

 

 

 

 

 

Please Submit:

1)Resume showing work experience. Include month/year of work experience, name and address of employer, contact telephone number for HR or administration to validate the work experience, and the name of supervisor. Failure to supply adequate information to meet state and federal instructor requirements will result in non-approval of application.

2)Proof of 24-hour BRN approved DSD class or transcript of college courses related to education programs in nursing.

3)Copy of active nursing license.

Facility / School / Agency or Employer Information:

Name

 

Telephone Number

 

 

 

 

 

 

 

Mailing Address (Number and Street or P.O. Box Number)

City

County

Zip Code

 

 

 

 

 

 

Administrator / Program Director Signature and Title

Printed Name

 

Date

 

 

 

 

 

 

Director of Nursing Signature

Printed Name

 

Date

 

 

 

 

 

 

Approved

 

FOR OFFICE USE ONLY

Date

 

By: Program Consultant

 

 

 

CDPH 279 (07/12)

This form is available on our website at: www.cdph.ca.gov

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