Form 445104 – Fill Out and Use This PDF

State of Illinois

Illinois Department of Public Health

HHA Agency Supervisor Qualification Review Form

HOME HEALTH AGENCY ONLY

Attachment B - Agency Supervisor Qualification Review Form

Section 245.30 of the 77 Illinois Administrative Code requires this position to be filled by an individual who is a registered nurse who has completed a baccalaureate degree program and has at least one year of nursing experience as a Bachelor of Science of Nursing; or a registered nurse without a baccalaureate degree, who has at least three years of nursing experience as an Registered Nurse within the last five years (two of those years in a home health agency, a community health program caring for the sick, or a family centered nursing program in a community health agency). Section 245.20 defines a registered nurse as a person currently licensed as an Registered Nurse under the Illinois Nursing Act.

Home Health Agency Name

Address

City

State

ZIP Code

Agency Supervisor Information

Last Name

First Name

Middle Initial

Address

City

State

ZIP Code

Daytime Phone number (include area code and extension)

Section 245.30 requires that the agency supervisor must be a Registered Nurse.

Indicate the highest educational level obtained:

ADN Diploma R.N. B.S.N. B.A. B.S. Master's Doctorate Please list the college(s) attended, the address, date of graduation, specialty and degree obtained.

Name of College

Address of College

City

State

ZIP Code

Date of Graduation

Specialty/Degree

Name of College

Address of College

City

State

ZIP Code

Date of Graduation

Specialty/Degree

Please list the high school attended, the address, and date of graduation.

Name of High School

Date of Graduation

Address of High School

City

State

ZIP Code

Form Number (445104)

Page 1 of 3

State of Illinois

Illinois Department of Public Health

HHA Agency Supervisor Qualification Review Form

List applicable professional licenses, registrations and/or certifications currently held with the license number, date of expiration and state that issued the license, registration or certification. ATTACH A COPY OF YOUR

CURRENT ILLINOIS LICENSE IF APPLICABLE. YOUR CURRENTLY EMPLOYER MUST BE THE AGENCY IDENTIFIED IN THIS APPLICATION. Please include a letter of intentions with this application (the agency supervisor is required to be full time upon licensure. Provide documentation that the applicant is resigning present employment upon licensure, or if working part time elsewhere, the applicant's other employment is outside the agency's hours of operation).

Describe your relevant work experience for the last five years.

(1)List your most recent position with THIS AGENCY FIRST and work backward.

(2)Give the starting and ending dates (month and year) for each employment and the weekly hours worked.

(3)Describe the administrative functions performed for each position, with each agency, that qualify you to function as the agency supervisor of a home health agency.

(4)Include the names, addresses and telephone numbers of organizations.

You may use an additional sheet of paper to complete this section. Resumes are not accepted in lieu of completion of this portion of the form.

Current Employer Name
Address of Current Employer
City							State		ZIP Code
Starting (month and year)					Ending (month and year)				Total Hours Worked Weekly
Duties

Previous Employer Name

Address of Previous Employer

City

State

ZIP Code

Starting (month and year)

Ending (month and year)

Total Hours Worked Weekly

Duties

Atttachment B-Agency Supervisor Qualification Review Form Page 2

Form Number (445104)

Page 2 of 3

State of Illinois

Illinois Department of Public Health

HHA Agency Supervisor Qualification Review Form

Previous Employer Name

Address of Previous Employer

City

State

ZIP Code

Starting (month and year)

Ending (month and year)

Total Hours Worked Weekly

Duties

Have you ever been convicted of a criminal offense?

Yes No

Are there any pending or administratively resolved issues concerning your professional license in Illinois or in another state?

Yes No

If you answered “yes” to either or both of the above statements, please describe the criminal offense and/or the pending or administratively resolved licensure issues in detail, including the state of administrative action [Section 245.130 b) 2]. You may attach an additional sheet of paper if necessary for the explanation.

I signify that the information contained in this form is true and correct to the best of my knowledge and belief. I realize that misrepresentation of this information at any time may be cause for denial of this application, or future revocation of a license.

Signature of Applicant (Original Only)

Date

Attachment B - Agency Supervisor Qualification Review Form Page 3
Form Number (445104)	Page 3 of 3