Dca Form 55M 11 – Fill Out and Use This PDF

Dca Form 55M 11 PDF Details

The DCA 55M 11 form is required by the California Department of Consumer Affairs for the Board of Vocational Nursing and Psychiatric Technicians. It is the official Clinical Facility Approval Application for vocational nursing and psychiatric technician programs. The form follows Title 16 of the California Code of Regulations, sections 2534 and 2588. Both a School Program Director and a Facility Director must complete and sign the form. Neither party can substitute for the other.

Sections of the Form

The DCA 55M-11 is divided into three main sections. Each section confirms a different aspect of the clinical facility's suitability for student training:

• Program Director Checklist. The program director reviews specific facility requirements. These include patient census levels, student-to-instructor ratios, and the range of clinical experiences available. Each item must be checked to confirm the facility meets that standard.
• Clinical Facility Information. This section records the facility's full legal name and California license number. It also captures the daily patient or client census, the types of services provided, and the contact details for the Facility Director and placement coordinator.
• Clinical Objectives Agreement. Both the program director and the facility director confirm that the facility's resources support the board-approved clinical objectives. The stated objectives must match the language in the program's approved instructional plan word for word.

Who Must Complete This Form

Two authorized representatives must complete the form. The School Program Director fills out the checklist and certifies that the clinical site is suitable for student training. The Facility Director confirms the facility's resources and agrees to support the listed training objectives. Both must sign and date the form in the correct fields. The board will not process a form signed by only one party.

We recommend reaching out to the Facility Director before you start the form. Confirming their availability in advance prevents delays after the document is prepared and ready to submit.

Regulatory Standards and Submission

The Board of Vocational Nursing and Psychiatric Technicians reviews each submitted form against the requirements in Title 16 of the California Code of Regulations. If the board approves the facility, students may begin their required clinical training hours at that site. Board approval must be obtained before any student is placed at a clinical facility.

Keep a copy of the submitted form and any board correspondence for your school records. Re-approval may be needed if the facility or the program's instructional objectives change significantly. For current submission instructions and processing timelines, refer to the California BVNPT forms page.

Related California Licensing Forms

These forms are commonly used alongside the DCA 55M-11 in California vocational health education programs:

• DCA License Renewal Form for renewing a California Department of Consumer Affairs professional license
• Clinical Experience Form for recording and verifying supervised clinical training hours
• 2DCA-02 Form for additional California DCA compliance documentation