Instructor/DSD Applicant Information: CA Nursing License Number, Applicant Mailing Address, Email Address, Telephone Number.
Submit the following: a resume showing verifiable work experience.
License: active RN or LVN license in California.
Type of Training to be Offered: Orientation and In-service Training or Nurse Assistant Training Program.
Signatures: Applicant Signature, Administrator/Owner Signature and Director of Nursing/RN Program Director Signature.
| Question | Answer |
|---|---|
| Form Name | CDPH 279 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 31 |
| Avg. time to fill out | 6 min |
| Edition | 11/2022 |
| Issuing agency | California Department of Public Health |
| Where to send | TPRU@cdph.ca.gov or fax (916) 636-6760 |
| Other names | CDPH 279, CDPH279, DSD application, Instructor or DSD application, Director of Staff Development application, Instructor or Director of Staff Development (DSD) Application |
| Official source | CDPH 279 (11/2022), California Department of Public Health |
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