Form Cdph 501 PDF Details

Are you a business owner in California? If so, you'll want to be familiar with Form CDPH 501. This form is used by the California Department of Public Health to collect information about your business. Completing and filing Form CDPH 501 is mandatory for all businesses operating in California. Let's take a closer look at what this form entails and how to complete it correctly.

In the list, there's some information relating to the form cdph 501. It is a good idea that you read this information before you decide to begin working with the file.

QuestionAnswer
Form NameForm Cdph 501
Form Length7 pages
Fillable?Yes
Fillable fields165
Avg. time to fill out34 min 49 sec
Other namesNHAPcdph, validating, cdph 501 fillable form, Copes

Form Preview Example

State of California - Health and Human Services Agency

California Department of Public Health (CDPH)

 

Nursing Home Administrator Program (NHAP)

 

MS 3302, P.O. Box 997416

 

Sacramento, CA 95899-7416

 

(916) 552-8780 FAX (916) 636-6108

 

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

 

 

 

 

PRECEPTOR'S NAME (Last)

(First)

(M.I.)

NHA LICENSE NUMBER

 

 

 

 

FACILITY NAME

FACILITY TELEPHONE NUMBER

FACILITY

FAX NUMBER

 

 

 

 

FACILITY ADDRESS (Number and Street Name)

(City)

(State)

(Zip Code)

 

 

 

 

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:

 

 

 

 

 

__________________

________

______________

__________

__________

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?__________

 

 

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)

 

 

 

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.

 

____________________________________

_____________________________

 

____________________________________

_____________________________

 

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)

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.

 

 

____________________________________

_____________________________

 

 

____________________________________

_____________________________

 

 

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)

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

B. WORK HABITS

E G F P

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

 

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

How to Edit Form Cdph 501 Online for Free

The objective regarding our PDF editor was to help it become as easy to use as it can be. You'll find the entire procedure of creating CDPH straightforward as soon as you stick to all of these actions.

Step 1: At first, pick the orange "Get form now" button.

Step 2: At this point, you are able to alter the CDPH. This multifunctional toolbar enables you to insert, get rid of, transform, highlight, as well as carry out several other commands to the words and phrases and fields within the file.

To be able to obtain the template, enter the details the application will request you to for each of the next parts:

NUMER fields to complete

Type in the appropriate details in the area GoodFair, Poor, CDPH, and Pageof.

stage 2 to filling out NUMER

It's essential to provide the significant particulars from the PreceptorsSignature, Date, AITsSignature, AIT, and Date field.

Finishing NUMER step 3

The area GoodFair, Poor, PreceptorsSignature, Date, AITsSignature, AIT, and Date should be where you add both sides' rights and responsibilities.

step 4 to completing NUMER

Finalize by taking a look at the following fields and preparing them as needed: GoodFair, and Poor.

step 5 to filling out NUMER

Step 3: Choose "Done". Now you can export your PDF document.

Step 4: It can be easier to have duplicates of your document. You can rest easy that we will not reveal or view your information.

Watch Form Cdph 501 Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .