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

DCA Form 55M 11 is a form used by the Department of Consumer Affairs to request that an individual be removed from "The Do Not Call Registry".

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Dca Form 55M 11 PDF 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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Question	Answer
Form Name	Dca Form 55M 11
Form Length	4 pages
Fillable?	Yes
Fillable fields	108
Avg. time to fill out	22 min 40 sec
Other names	bvnpt clinical facility approval, bvnpt facility form, 55m 11 bvpt, bvnpt facility application

12

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 students’ clinical 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?	Yes	No
• 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

How to Edit Dca Form 55M 11 Online for Free

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Step 1: On the web page, press the orange "Get form now" button.

Step 2: You'll find all the options that it's possible to use on the document once you've accessed the bvnpt facility approval application editing page.

The PDF document you desire to fill in will cover the following parts:

portion of gaps in dca form 55m 11

You have to submit the Instructions box with the essential particulars.

Entering details in dca form 55m 11 step 2

You may be required specific crucial data so that you can submit the ceT, AT, a, cALl, aRNI, A DEPARTMENT, DF, CONSUMER, AFFAIRS SECTION, I, Type SCHOOL, NAME, AND, CAMPUS and NAME, OF, CLINICAL, FACILITY part.

dca form 55m 11 ceTATacALlaRNIA, DEPARTMENTDFCONSUMERAFFAIRS, SECTIONIType, SCHOOLNAMEANDCAMPUS, and NAMEOFCLINICALFACILITY blanks to fill out

The STREET, CITY, STATE, ZIP, FACILITY, TELEPHONE FACILITY, FAX NAME, OF, FACILITY, ADMINISTRATOR, DIRECTOR PLACEMENT, CONTACT, PERSON FOR, FACILITY, CONTACT, PERSON TELEPHONE, and EMAIL, ADDRESS area is the place where both sides can put their rights and responsibilities.

Completing dca form 55m 11 step 4

End by taking a look at the following areas and preparing them as needed: private, practice, office, etc Md, Sur, g AVERAGE, DAILY, CENSUS, FOR, FACILITY DD, for, PT, programs Other, describe Please, complete, the, following, table PLEASE, ANSWER, THE, FOLLOWING, QUESTIONS Yes, Yes, Yes, Yes, Yes, Yes, Yes and NoN, oN, oN, oN, oN, oNo

stage 5 to completing dca form 55m 11

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