Form 445104 PDF Details

Are you a recent college graduate who is feeling overwhelmed and uncertain about what to do next? If so, you're not alone. The transition from student to working professional can be daunting, but with the right tools and resources at your disposal, it doesn't have to be. One great resource for recent graduates is IRS Form 445104. This form can help you determine your tax obligations and identify the various tax credits and deductions available to you. Reviewing this form can be helpful in ensuring that you are taking advantage of all of the tax breaks available to you. So if you're feeling lost when it comes to taxes, Form 445104 is a good place to start. With the right information, filing your taxes can be simpler than you think!

QuestionAnswer
Form NameForm 445104
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesCOOS HHA supervisor qualification review form attmnt b home health formcomcomplaints

Form Preview Example

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

How to Edit Form 445104 Online for Free

If you need to fill out Form 445104, it's not necessary to download any software - simply use our PDF editor. The tool is constantly updated by our staff, acquiring useful functions and becoming greater. To get started on your journey, take these basic steps:

Step 1: Click the "Get Form" button above on this page to access our editor.

Step 2: With our handy PDF file editor, you could do more than just fill in blank form fields. Try each of the features and make your docs appear professional with customized textual content added in, or adjust the file's original input to perfection - all that backed up by an ability to incorporate any pictures and sign it off.

This document will need some specific details; in order to ensure accuracy, please be sure to heed the guidelines hereunder:

1. The Form 445104 will require specific information to be typed in. Ensure that the subsequent blank fields are completed:

Form 445104 conclusion process explained (part 1)

2. Given that this segment is done, you need to include the necessary particulars in ADN, Diploma RN, BSN, Masters, Doctorate, Please list the colleges attended, Name of College, Address of College, City, Date of Graduation, SpecialtyDegree, Name of College, Address of College, City, and Date of Graduation in order to proceed to the next step.

BSN, City, and SpecialtyDegree inside Form 445104

3. Throughout this step, check out Name of High School, Address of High School, City, Form Number, Date of Graduation, State, ZIP Code, and Page of. Each of these are required to be taken care of with highest precision.

Form 445104 conclusion process detailed (step 3)

4. Filling in HHA Agency Supervisor, List applicable professional, and Describe your relevant work is paramount in this next form section - be sure to spend some time and be mindful with each blank area!

Tips on how to fill out Form 445104 step 4

Regarding Describe your relevant work and HHA Agency Supervisor, be certain you get them right in this current part. Both of these are the most important ones in this page.

5. The very last step to finish this PDF form is critical. Ensure that you fill in the displayed blank fields, and this includes 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, and ZIP Code, before submitting. If you don't, it could give you a flawed and probably unacceptable form!

Writing section 5 of Form 445104

Step 3: Before moving on, double-check that blank fields were filled in the proper way. The moment you think it is all fine, click “Done." Get hold of your Form 445104 as soon as you register online for a 7-day free trial. Quickly view the form inside your FormsPal account page, together with any edits and changes automatically kept! We don't share the information you type in when dealing with documents at our website.

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