Dca Form 55M 11 PDF Details

The DCA 55M 11 form stands as a crucial document within the framework of California's vocational nursing and psychiatric technician education, streamlining the interaction between educational institutions and clinical facilities. Managed by the California Department of Consumer Affairs under the guidance of the Board of Vocational Nursing and Psychiatric Technicians, it facilitates rigorous compliance with the California Code of Regulations, Title 16, sections 2534 and 2588. The detailed form is meticulously divided into sections requiring joint completion by both the School Program Director and the Facility Director to ensure a comprehensive understanding and adherence to the required educational standards. Each section aims to validate the suitability of a clinical facility for student placements by examining the facility's available services, patient demographics, and the student's ability to achieve their clinical objectives within the said environment. Furthermore, it underscores the necessity for clarity and legibility in its completion, emphasizing the importance of providing accurate and unaltered information to maintain the integrity of the application process. Attachments of clinical objectives, aligned with the board's approved instructional plan, must accompany the form, highlighting specific outcomes students are anticipated to achieve. This form represents a critical step in ensuring that vocational nursing and psychiatric technician students receive their practical training in environments that are not only conducive to their learning but also aligned with regulatory standards and educational goals.

QuestionAnswer
Form NameDca Form 55M 11
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesbvnpt facility approval application, bvnpt clinical facility approval, bvnpt facility form, bvnpt facility applical

Form Preview Example

eTAT ■ a .. 0AL l .. 0RNIA

c:1 c:a

DEPARTMENT DF CONSUMER AFFAIRS

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205, Sacramento, CA 95833-2945 Phone 916-263-7800 Fax 916-263-7866 Web www.bvnpt.ca.gov

Instructions to School Program Director:

Please complete SECTIONS I and III of this form to demonstrate compliance with California Code of Regulations (CCR), Title 16, sections 2534 and 2588.

To assure successful submissions:

Complete all sections of the form legibly with no information crossed/whited out and replaced with different information. This form is an official document; therefore, forms with alterations will not be accepted.

Submit separate forms for each program (PT or VN) or school campus if the facility will be used by more than one program or campus of a school.

Check the form before submission to assure that all requested information has been included, all required signatures are present, and the required facility-specific clinical objectives are attached.

Attach only clinical objectives from the Board-approved Instructional Plan that will be able to be accomplished at this facility.

Complete Sections I and III, and attach applicable clinical objectives before giving the form to the facility contact person for review. The facility contact person should then be directed to complete Section II.

Upon completion the application should be submitted via email to the program’s assigned Nursing Education Consultant.

Check list for Program Directors before giving form to facility to complete:

Form is completed legibly in ink with no crossed-out or whited-out information.

Separate form has been used for each campus or program (if school offers VN and PT programs). All required information is included in Sections I and III.

Clinical Objectives from the Board-approved Instructional Plan specific to this facility are attached. The Program Director signed and dated the form.

Check list for Program Directors after Section II has been completed by Facility Administrator/Director:

All required information is included.

The Facility Administrator/Director signed and dated the form.

(55M-11 03/2018)

Instructions

eTAT ■ a .. 0AL l .. 0RNIA

c:1 c a

DEPARTMENT DF CONSUMER AFFAIRS

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205, Sacramento, CA 95833-2945 Phone 916-263-7800 Fax 916-263-7866 Web www.bvnpt.ca.gov

CLINICAL FACILITY APPROVAL APPLICATION FORM

SECTION I – Type

THIS SECTION IS TO BE COMPLETED BY SCHOOL PROGRAM DIRECTOR

SCHOOL NAME AND CAMPUS:

VN

PT

1.NAME OF CLINICAL FACILITY:

ADDRESS OF LOCATION WHERE CLINICAL EXPERIENCE WILL TAKE PLACE:

STREET:

CITY:

STATE:

ZIP:

FACILITY TELEPHONE #: ____________________________________________________________________________

FACILITY FAX # _____________________________________________________________________________________

 

 

2. NAME OF FACILITY ADMINISTRATOR/DIRECTOR:

3. NAME/TITLE OF PERSON RESPONSIBLE FOR STUDENT

 

PLACEMENT (CONTACT PERSON):

 

 

 

4.FOR FACILITY CONTACT PERSON:

TELEPHONE #: _________________________________________________________________________________________

EMAIL ADDRESS: ____________________________________________________________________________________

55M-11 (03/2018)

Page 1

SECTION II - Type

THIS SECTION IS TO BE COMPLETED BY THE FACILITY DIRECTOR

FACILITY ADMINISTRATOR/DIRECTOR: Please complete the following information for your facility. Be as descriptive as possible regarding your client population and the type of care offered at your location. After completion return the form to the Program Representative.

1.TYPE OF FACILITY (type of care designation, e.g. acute care, skilled nursing facility, long term care, clinic, private practice office, etc.)

2.CLIENT POPULATION: Check All That Apply

Med/Surg

OB

Peds Mental Health

DD (for PT programs)

Other (describe):

3.AVERAGE DAILY CENSUS FOR FACILITY:

4. Please complete the following table:

Units/Services available for student assignment

Average Daily Census for

Unit/Services

# Students Possible Per

Unit/Services Per Shift

Days of Week Available for Student Assignment

Shifts Available for Student

Assignment

5. PLEASE ANSWER THE FOLLOWING QUESTIONS.

A. Were the student’s clinical objectives given to you for review?

Yes

No

B. Are the studentsclinical objectives achievable in your facility?

Yes

No

C. Does your facility limit the ratio of instructors to students? # ____ instructors to # ____ students.

Yes

No

D. Can the instructor assign students to multiple units and be responsible for students on all assigned units?

Yes

No

E. Does your facility require facility orientation for students and/or faculty?

Yes

No

F. Are students required to complete a special facility orientation?

Yes

No

G. Is the instructor free to make assignments which correlate with current theory classes,

Yes

No

including administration of medications, treatments, use of equipment and charting?

 

 

H. Did you discuss the following with the program representative?

Yes

No

Policies and procedures regarding student placement?

Documentation and charting methodologies?

Yes

No

Are students allowed to access the patient/resident electronic records?

Yes

No

Facility emergency and non-emergency procedures?

Yes

No

Name/Title of Program Representative with whom you discussed this application: ___________________________________

6. THIS SIGNATURE CONFIRMS THAT I HAVE REVIEWED AND AGREE WITH THE CONTENTS OF THIS FORM AND ALL ATTACHMENTS.

FACILITY DIRECTOR’S Signature: __________________________________________Date: _____________________

FACILITY DIRECTOR’S Printed Name: _______________________________________Date: ______________________

55M-11 (03/2018)

Page 2

SECTION III - Type

THIS SECTION IS TO BE REVIEWED AND COMPLETED BY THE SCHOOL PROGRAM DIRECTOR

1. The following information regarding your program’s use of the facility must be completed for each applicable term/level.

-

A. Term/Level of Student &Content

B.Weeks/Term Each Student Will Be at This Facility

C.Unit/Services Used Each Term

D.Number of Students/Unit

E.Total Hours Per Week/Student

2.What is the maximum number of weeks during the program that a student would be at this facility?

REMINDER: Copies of the students’ clinical objectives from the Board-approved Instructional Plan that are expected to be achieved at this facility must be attached to this application before giving the application to the facility.

-

3. PROGRAM DIRECTOR: PLEASE ANSWER THE FOLLOWING QUESTIONS.

Did you discuss the following topics with the facility:

 

 

A. Course description and student clinical objectives?

Yes

No

B. Specific nursing care and procedures required for student achievement of clinical objectives?

Yes

No

4. I HEREBY CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT.

PROGRAM DIRECTOR’S Signature: _________________________________________ Date: __________________________

PROGRAM Director’s Printed Name: _________________________________________ Date: ________________________

FOR BOARD USE ONLY

NAME OF FACILITY REPRESENTATIVE SPOKEN WITH: __________________________________

Approved Denied

COMMENTS:

 

BOARD CONSULTANT’S SIGNATURE: ______________________________________________________

APPROVAL DATE: ____________________________________________

55M-11 03/2018)

Page 3

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portion of gaps in bvnpt clinical facility approval

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Entering details in bvnpt clinical facility approval step 2

You may be required specific crucial data so that you can submit the ceTAT a, DEPARTMENT DF CONSUMER AFFAIRS, Board of Vocational Nursing and, CLINICAL FACILITY APPROVAL, SECTION I Type, THIS SECTION IS TO BE COMPLETED BY, SCHOOL NAME AND CAMPUS, and NAME OF CLINICAL FACILITY part.

bvnpt clinical facility approval ceTAT  a, DEPARTMENT DF CONSUMER AFFAIRS, Board of Vocational Nursing and, CLINICAL FACILITY APPROVAL, SECTION I  Type, THIS SECTION IS TO BE COMPLETED BY, SCHOOL NAME AND CAMPUS, and NAME OF CLINICAL FACILITY blanks to fill out

The ADDRESS OF LOCATION WHERE CLINICAL, STREET, CITY, STATE, ZIP, FACILITY TELEPHONE, FACILITY FAX, NAME OF FACILITY, NAMETITLE OF PERSON RESPONSIBLE, PLACEMENT CONTACT PERSON, FOR FACILITY CONTACT PERSON, and TELEPHONE area is the place where both sides can put their rights and responsibilities.

Completing bvnpt clinical facility approval step 4

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stage 5 to completing bvnpt clinical facility approval

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