The Doea Hospice Adrd 001 form serves as a comprehensive application for individuals and entities seeking certification to provide hospice training specifically focused on Alzheimer's Disease or Related Disorders (ADRD). As delineated by rules 58A-2.027 and 58A-2.028 of the Florida Administrative Code (FAC) and under the provisions of section 400.6045(1) of the Florida Statutes (F.S.), this application process is critical for ensuring that trainers are thoroughly vetted and qualified. Applicants are required to submit detailed personal and professional information, alongside evidence of their educational credentials and experience with Alzheimer's care. These stipulations include but are not limited to, holding a Bachelor's or Master's degree in a relevant field, possessing licensure as a registered nurse, and providing proof of teaching experience or practical experience in caring for individuals with Alzheimer's or related disorders. Additionally, the form outlines necessary documentation, such as official transcripts, licenses, and proof of specialized training or experience, underscoring the meticulous screening process to uphold standards in caregiver training for individuals with Alzheimer's Disease and related disorders. This structured approach ensures that certified hospice training providers possess the requisite knowledge and experience to offer high-quality care and education.
| Question | Answer |
|---|---|
| Form Name | Doea Form Hospice Adrd 001 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | ट्रेनिंग का फुल फॉर्म, treining ka full form, in training ful form of pt it wt, fill full form |
APPLICATION FOR
HOSPICE TRAINING PROVIDER CERTIFICATION ALZHEIMER’S DISEASE OR RELATED DISORDERS TRAINING
Incorporated by reference in rule
SPECIAL INSTRUCTIONS: Please read this application carefully and fill in all of the blanks. Return the completed application along with written proof of your eligibility to:
By Regular or Express Mail:
Training Academy on Aging
School of Aging Studies University of South Florida 13301 Bruce B. Downs Blvd.
FMHI - MHC 1300
Tampa, FL 33612
FOR AGENCY USE ONLY:
ID# ____________Date
Type: ______________
Received
Acknowledged
Incomplete
Need More Information
Other ______________
Approved Comments___________________
___________________________
PART
The information provided below is public record and reflects ownership of submitted materials.
Name: ______________________________________________________________________________________
Company Name (if applicable):____________________________________________________________
Address:____________________________________________________________________________________________________________
Apt. #
_____________________________________________________________________________________________________________________
|
City |
State |
Zip Code |
County |
Telephone: ( |
)___________________ |
Fax: ( |
)__________________ |
Part 2: Application Affidavit
I HEREBY AFFIRM THAT ALL INFORMATION INCLUDED IN THIS APPLICATION IS TRUE AND CORRECT.
Print or type name of applicant: ___________________________________________
Signature of applicant: __________________________________________________
Date: _________________
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APPLICANT CREDENTIALS
For Alzheimer’s Disease or Related Disorders Training
(Incorporated by reference in Rules
Part 3 - Applicant Credentialing Requirements Checklist
In order to be eligible for certification, you must provide proof of one the following (see substitutions and exceptions below):
A Bachelor’s degree in a
Licensure as a registered nurse.
In addition to the above requirements, you must provide proof of one of the following criteria:
Possess teaching or training experience as an educator of care givers for persons with Alzheimer’s Disease or Related Disorders; or
Have one (1) year of practical experience in a program providing care to persons with Alzheimer’s Disease or Related Disorders; or
Have completed a specialized training program in Alzheimer’s Disease or Related Disorders from a university or an accredited health care or human service or gerontology continuing education provider.
Substitutions
A Master’s degree in a
Teaching or training experience as an educator of caregivers for persons with Alzheimer’s Disease or Related Disorders may substitute on a year-
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Part 4 – Applicant Documentation Checklist
The following documents may be used as written proof of your eligibility and must be enclosed with your application:
Copy of your final official transcripts of Baccalaureate degree in a
Copy of your current license as a registered nurse.
Letter from employer (on company letterhead) noting starting and ending dates of service and types of services provided to persons with Alzheimer’s Disease or Related Disorders.
Documentation of successful completion of approved university based coursework in caring for persons with Alzheimer’s Disease or Related Disorders.
Certificate/s of successful completion of specialized training program/s in caring for persons with Alzheimer’s disease or Related Disorders from a university or an accredited health care or human service or gerontology continuing education provider.
Documentation of successful completion of CEU approved presentations, workshops, or seminars in caring for persons with Alzheimer’s Disease or Related Disorders.
Copy of your final official transcripts of Master’s degree in a health related field.
Documentation of successful completion of training and continuing education consistent with the requirements of section 400.4178, or completion of training consistent with the requirements of sections 400.1755 or 400.5571, Florida Statutes.
IMPORTANT INFORMATION/INSTRUCTIONS:
Please send this application along with written proof of eligibility (see above, documentation checklist) to the address on the front of this application. No application will be accepted without written proof of eligibility.
Within thirty (30) calendar days from the date your application is received, your credentials will be reviewed and you will be sent written notification of the status of your application.
You must be an approved training provider and utilize an approved training curriculum prior to commencing training activities, pursuant to rule
Please note: ANY MATERIALS SUBMITTED WITH THIS APPLICATION CANNOT BE RETURNED.
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