Bdnpt Clinical Facility Approval Application Details

Did you know that the Department of the Treasury offers a form to help US citizens living abroad file their taxes? The form is called Dca Form 55M 11, and it can be used to report worldwide income. If you're not sure how to use the form or if you need help completing it, keep reading. We'll provide an overview of what's required and offer some tips for filing your taxes.

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QuestionAnswer
Form NameDca Form 55M 11
Form Length2 pages
Fillable?Yes
Fillable fields84
Avg. time to fill out17 min 22 sec
Other names55m 11 bvpt, dca form 55m 11, bvnpt facility form, bdnpt clinical facility approval application

Form Preview Example

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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

INSTRUCTIONS: Please complete both front and back of this form to demonstrate compliance with Title 16, California Code of Regulations (CCR) §§ 2534 and 2584. Submit separate forms for multiple campuses or if use of the facility is proposed for both Vocational Nurse (VN) and Psychiatric Technician (PT) programs. ALL REQUESTED INFORMATION IS MANDATORY. FAILURE TO

PROVIDE ALL INFORMATION WILL RESULT IN THE APPLICATION BEING REJECTED AS INCOMPLETE.

FOR BOARD USE ONLY

Approved By:

Date Approved:

PRINT LEGIBLY IN INK

SCHOOL NAME AND CAMPUS: ___________________________________________________________________ VN

 

 

PT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. NAME OF CLINICAL FACILITY: ________________________________________________________________________________

 

ADDRESS: _____________________________________________________________________________________________________

 

CITY: ________________________________________________________

STATE:

 

 

ZIP:

 

 

 

 

 

TELEPHONE #: (

)__________________________________________

FAX #: (

) _____________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

NAME OF FACILITY ADMINISTRATOR:

 

3. NAME OF FACILITY DIRECTOR:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

CONTACT PERSON: _________________________________ TELEPHONE #: (

)______________ EMAIL: _____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

TYPE OF FACILITY:

 

 

 

 

6. LICENSE STATUS (Check One):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Licensed

 

 

Certified

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

CLIENT POPULATION: Check All That Apply

 

8. AVERAGE DAILY CENSUS FOR FACILITY:

 

 

 

 

 

 

Adults

 

Peds

 

Geriatrics

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. FACILITY DIRECTOR: PLEASE INDICATE THE UNITS/SERVICES (OB, MED/SURG, PEDS, ETC.) AVAILABLE FOR

STUDENT ASSIGNMENT FROM THIS PROGRAM, THE AVERAGE DAILY CENSUS FOR EACH AND THE MAXIMUM NUMBER OF STUDENTS FROM THIS PROGRAM THAT EACH UNIT CAN ACCOMMODATE.

UNITS/SERVICES

Average Daily Census for

Unit/Services

# Students Possible Per Unit/Services

10. FACILITY DIRECTOR: PLEASE ANSWER THE FOLLOWING QUESTIONS.

D1##Zhuh#wkh#vwxghqwᄊv#folqlfdo#remhfwlyhv#jlyhq#wr#|rx#iru#uhylhzB###

B.Are the studentsᄊ#clinical objectives achievable in your facility?

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

D.Will the instructor(s) have an orientation to your facility?

E.Are studentsᄊ#required to complete a special facility orientation?

F.Is the instructor free to make assignments which correlate with current theory classes, including administration of medications, treatments, use of equipment and charting?

G.Is the instructor free to move students to areas where immediate, pertinent learning is available, even with short notice?

H.Is adequate space available for classes and conferences?

I.Is this space available for uninterrupted use by students and faculty? If not, what other arrangements have been made?

Yes

 

 

 

 

No

 

Yes

 

 

 

 

No

 

 

Yes

 

 

 

 

No

 

 

 

 

 

 

Yes

 

 

 

 

No

 

 

 

 

 

 

 

Yes

 

 

 

 

No

 

 

 

 

 

 

 

Yes

 

 

 

 

No

 

 

 

 

 

 

 

Yes

 

 

 

 

No

 

 

 

 

 

 

 

Yes

 

 

 

 

No

 

 

 

 

 

 

 

 

Yes

 

 

 

 

No

 

 

 

 

See page 2 for Facility Signature.

OVER

 

 

55M-11 (09/13)

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11. THE FOLLOWING INFORMATION MUST BE COMPLETED FOR EACH STUDENT LEVEL. IF THE CLINICAL EXPERIENCE

WILL BE ACHIEVED AT A SATELLITE SITE, CHECK THIS BOX.

HOW MANY WEEKS WILL EACH STUDENT SPEND AT THIS FACILITY? (i.e. # weeks/student at facility) ____________________

A. Level of Student

B. Starting Calendar Date

C. Unit / Services

D. Number of Students

E. Days of Week

F. Start & End Times of Day

G. Total Hours Per Week *

H. Pre-Conference Days & Times

I.Post-Conference Days & Times

J.Instructor on Site

(List Days & Times)

*# Days Per Week times # Hours Per Day must equal Total Hours per Week

12. Copies of the following documents must be attached.

CLINICAL OBJECTIVES FOR EACH STUDENT LEVEL TO BE ACHIEVED AT THIS FACILITY

PLAN FOR FACULTY ORIENTATION TO FACILITY

13. PROGRAM DIRECTOR: PLEASE ANSWER THE FOLLOWING QUESTIONS.

 

 

Did you discuss 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

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Yes

 

 

 

No

 

 

 

 

G1##Wkh#idflolw|ᄊv#grfxphntation and charting methodologies?

Yes No

E. Location of facility emergency and non-emergency equipment?

Yes No

F. Facility emergency and non-emergency procedures?

 

 

Yes

 

 

No

G. Scheduling of facilty conference rooms?

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

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

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IDFLOLW\#Gluhfwruᄊv#Sulqwhg#Qdph=##bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb__________ Date: ____________________________

15.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.

SURJUDP#Gluhfwruᄊv#Vljqdwxuh=##bbbbbbbbbb_______________________________________ Date: ____________________________

SURJUDP#Gluhfwruᄊv#Sulqwhg#Qdph=##bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb######Gdwh=##bbbbbbbbbbbbbbbbbbbbbbbbbbbb#

FOR BOARD USE ONLY

NAME OF FACILITY REPRESENTATIVE SPOKEN WITH: _________________________________________ Approved

Denied

COMMENTS:

 

 

 

 

 

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55M-11 (09/13)

How to Edit Dca Form 55M 11

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Step 1: Click on the "Get Form Here" button.

Step 2: So, you may alter your 55m 11 bvpt. Our multifunctional toolbar allows you to include, erase, modify, highlight, as well as carry out other commands to the content and areas inside the file.

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bvnpt facility applical spaces to consider

Complete the UNITS/SERVICES, Average Daily Census for, ### # D1#, medications, Yes Yes, Yes, Yes, Yes, Yes, Yes, and No No field with all the information requested by the software.

step 2 to entering details in bvnpt facility applical

It is essential to write specific information inside the field WILL BE ACHIEVED AT A SATELLITE, HOW MANY WEEKS WILL EACH STUDENT, CLINICAL OBJECTIVES FOR EACH, PLAN FOR FACULTY ORIENTATION TO, and Did you discuss with the facility:.

step 3 to completing bvnpt facility applical

The Did you discuss with the facility:, IDFLOLW\#Gluhfwruᄊv#Sulqwhg#Qdph=#, INFORMATION CONTAINED IN THIS, SURJUDP#Gluhfwruᄊv#Vljqdwxuh=#, NAME OF FACILITY REPRESENTATIVE, Approved, Denied, and FOR BOARD USE ONLY field will be applied to note the rights or obligations of both sides.

Filling in bvnpt facility applical part 4

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