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

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.

CLINICAL FACILITY APPROVAL APPLICATION FORM

SECTION I – Type

THIS SECTION IS TO BE COMPLETED BY SCHOOL PROGRAM DIRECTOR

1.NAME OF CLINICAL FACILITY:

ADDRESS OF LOCATION WHERE CLINICAL EXPERIENCE WILL TAKE PLACE:

STREET:

4.FOR FACILITY CONTACT PERSON:

TELEPHONE #: _________________________________________________________________________________________

EMAIL ADDRESS: ____________________________________________________________________________________

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.)

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.

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: ______________________

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.

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

BOARD CONSULTANT’S SIGNATURE: ______________________________________________________

APPROVAL DATE: ____________________________________________