State of California - Health and Human Services Agency |
California Department of Public Health (CDPH) |
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Nursing Home Administrator Program (NHAP) |
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MS 3302, P.O. Box 997416 |
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Sacramento, CA 95899-7416 |
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(916) 552-8780 FAX (916) 636-6108 |
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NHAP@cdph.ca.gov |
ADMINISTRATOR-IN-TRAINING (AIT) EVALUATION REPORT
Please submit this report within ten (10) days after the completion of each training quarter. This form will also need to be submitted if there is a change in the AIT's 1,000 hour training program, change in preceptor, facility, or the stop, suspension or termination of program.
AIT'S NAME (Last) |
(First) |
(M.I.) |
AIT NUMBER |
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PRECEPTOR'S NAME (Last) |
(First) |
(M.I.) |
NHA LICENSE NUMBER |
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FACILITY NAME |
FACILITY TELEPHONE NUMBER |
FACILITY |
FAX NUMBER |
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FACILITY ADDRESS (Number and Street Name) |
(City) |
(State) |
(Zip Code) |
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FIRST QUARTER
Total AIT training hours for the quarter: ______ Start Date: ______ End Date: _______
Actual hours per week of supervised training: __________
PROGRAM CHANGES THIS QUARTER (Briefly describe in detail):
☐Supporting documentation attached validating first quarter completion and/or changes.
How would you rate the AIT’s attendance? ☐ Excellent ☐ Good ☐ Fair ☐Poor How many hours did you personally train this AIT?__________
Did anyone else assist the AIT with their training? If so, please list name and title.
Please list the training topics that were covered during this quarter:
____________________________________ _____________________________
____________________________________ _____________________________
CDPH 501 (7/21) |
Page 1 of 7 |
Do you, as a preceptor, recommend the AIT progress to the next quarter of training? ☐Yes |
☐ No |
If no, please explain: |
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__________________ |
________ |
______________ |
__________ |
__________ |
Preceptor’s Signature |
Date |
AIT’s Signature |
AIT# |
Date |
SECOND QUARTER
Total AIT training hours for the quarter: ______ Start Date: ______ End Date: _______
Actual hours per week of supervised training: __________
PROGRAM CHANGES THIS QUARTER (Briefly describe in detail):
☐Supporting documentation attached validating second quarter completion and/or changes.
How would you rate the AIT’s attendance? ☐ Excellent |
☐ Good |
☐ Fair |
☐Poor |
How many hours did you personally train this AIT?__________ |
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Did anyone else assist the AIT with their training? If so please list names and titles.
Please list the training topics that were covered during this quarter
____________________________________ _____________________________
____________________________________ _____________________________
Do you, as a preceptor, recommend the AIT progress to the next quarter of training? ☐ Yes ☐No If no, please explain:
_________________ |
________ |
______________ |
__________ |
__________ |
Preceptor’s Signature |
Date |
AIT’s Signature |
AIT# |
Date |
CDPH 501 (7/21) |
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Page 2 of 7 |
THIRD QUARTER
Total AIT training hours for the quarter: ______ Start Date: ______ End Date: _______
Actual hours per week of supervised training: __________
PROGRAM CHANGES THIS QUARTER (Briefly describe in detail):
☐Supporting documentation attached validating third quarter completion and/or changes.
How would you rate the AIT’s attendance? ☐ Excellent ☐ Good ☐ Fair ☐Poor How many hours did you personally train this AIT?__________
Did anyone else assist the AIT with their training? If so please list names and titles.
Please list the training topics that were covered during this quarter. |
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____________________________________ |
_____________________________ |
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____________________________________ |
_____________________________ |
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Do you, as a preceptor, recommend the AIT progress to the next quarter of training? ☐Yes |
☐No |
If no, please explain: |
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_________________ |
________ |
______________ |
__________ |
__________ |
Preceptor’s Signature |
Date |
AIT’s Signature |
AIT# |
Date |
CDPH 501 (7/21) |
Page 3 of 7 |
FOURTH QUARTER
Total AIT training hours for the quarter: ______ Start Date: ______ End Date: _______
Actual hours per week of supervised training: __________
PROGRAM CHANGES THIS QUARTER (Briefly describe in detail):
☐Supporting documentation attached validating fourth quarter completion and/or changes. How would you rate the AIT’s attendance? ☐ Excellent ☐ Good ☐ Fair ☐Poor How many hours did you personally train this AIT?__________
Did anyone else assist the AIT with their training? If so please list names and titles.
Please list the training topics that were covered during this quarter. |
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____________________________________ |
_____________________________ |
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____________________________________ |
_____________________________ |
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Do you, as a preceptor, recommend the AIT progress to the next quarter of training ☐Yes |
☐No |
If no, please explain: |
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_________________ |
________ |
______________ |
__________ |
__________ |
Preceptor’s Signature |
Date |
AIT’s Signature |
AIT# |
Date |
CDPH 501 (7/21) |
Page 4 of 7 |
AIT Name (PRINT):_________________
ADMINISTRATOR-IN-TRAINING (AIT) EVALUATION REPORT
This is a confidential evaluation of your overall performance during the 1,000 hour AIT program. This information is for you to use as a guide to improve your performance as a future nursing home administrator.
E = EXCELLENT G = GOOD F = FAIR |
P = POOR |
A. ATTITUDE |
E G F P |
1.Adapted to changing circumstances
2.Enthusiastic and positive
3.Versatile and willing to accept changes in job assignments
4.Follows facility rules, regulations
5.Accepts suggestions for work improvement and follows through
6.Can be entrusted to perform at the NHA level with minimum supervision
7.Cooperates with supervisor and shows respect at all times
8.Handles complaints quickly and takes appropriate steps to ensure complaint is not repeated
1.Organization skills
2.Completes job assignments in a timely manner
3.Leadership skills
4.Exercises good judgment
5.Performs assignments safely
6.Alert to changing conditions and follows through appropriately
7.Prioritizes job assignments well-efficient
8.Negotiation skills
9.Follows regulations governing nursing homes
10.Knowledgeable of regulatory resources
11.Reviews nursing home functions and ensures compliance with regulatory requirements
12.Attendance records
13.Timely notification of absences
14.Processes confidential request or medical information appropriately
CDPH 501 (7/21) |
Page 5 of 7 |
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AIT Name (PRINT):_________________ |
E = EXCELLENT |
G = GOOD F = FAIR P = POOR |
C. QUALITY OF WORK |
E G F P |
1.Performs job assignments to meet facility standards
2.Copes and performs well in unusual and emergency situations
3.Written and verbal communications are clear and understandable
4.Ensures that assignments are completed neatly and according to proper regulatory standard
D. RELATIONSHIP WITH STAFF |
E G F |
P |
1.Gets along well with other employees
2.Team player and encourages teamwork
3.Maintains professionalism with staff
4.Courteous and patient when dealing with staff
5.Willing to help other employees
6.Serves as a resource for staff
7.Keeps staff informed of existing policies/procedures/changes
E. INTERPERSONAL SKILLS |
E |
G F |
P |
1.Encourages and creates a positive work environment
2.Gives and takes constructive criticism
3.Meet changing priorities with a positive attitude
4.Maintains a positive and cooperative work environment
F. RESIDENT AND FAMILY RELATIONSHIPS |
E G F P |
1.Displays genuine concern for patients and their families concerns/feelings
2.Respects and honors resident's rights
3.Does their utmost to maintain resident's dignity and self-respect
4.Communicates with residents or family members regarding their care or concerns
5.Follows "Care Plans" and reports change in resident's conditions promptly
6.Greets family and others with a smile/friendly
7.Processes confidential request or medical information appropriately
8.Handles complaints assertively
CDPH 501 (7/21) |
Page 6 of 7 |
AIT Name (PRINT):_________________
E G F P
OVERALL RATING
ADDITIONAL COMMENTS: (Use space provided below and additional paper to comment or correct the AIT's performance for evaluation ratings of "Fair" or "Poor" listed above, or to explain termination of the AIT program, or to describe anything not covered by this evaluation). Please offer specific commendations or recommendations for improvement.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
This evaluation has been discussed with me and I/we certify under penalty of perjury that the information obtained in this document is both true and correct
AIT's Signature ______________________ |
Date _____________ |
Preceptor's Signature _________________ |
Date _____________ |
*Support rating for response to leadership question on page
CDPH 501 (7/21) |
Page 7 of 7 |
