Licensure 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 Length4 pages
Fillable?Yes
Fillable fields321
Avg. time to fill out32 min 38 sec
Other namesNHAP, Copes, AIT, cdph 501 fillable form

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) 552-8777

 

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)

(Middle)

AIT NUMBER

 

 

 

 

PRECEPTOR'S NAME (Last)

(First)

(Middle)

NHA LICENSE NUMER

 

 

 

 

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 CHANGE(S) THIS QUARTER (briefly explain 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.

 

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 CHANGE(S) THIS QUARTER (briefly explain 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 name and title.

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 (02/12)

Page 1 of 4

 

 

 

AIT Name (Print):

 

 

 

 

 

 

THIRD QUARTER - Total AIT training hours for the quarter: _____

Start Date:

End Date:

 

 

 

Actual hours per week of supervised training: ________

 

 

 

 

 

 

 

 

PROGRAM CHANGE(S) THIS QUARTER (briefly explain 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 name and title.

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

 

FOURTH QUARTER - Total AIT training hours for the quarter: _____

Start Date

 

 

 

End Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Actual hours per week of supervised training: ________

 

 

 

 

 

 

 

 

 

PROGRAM CHANGE(S) THIS QUARTER (briefly explain 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 name and title.

Please list the training topics that were covered during this quarter.

Preceptor's Signature

Date

AIT's Signature

 

AIT #

Date

SUMMARY

 

 

 

 

 

1.

In general, what is your overall rating of the AIT?

Excellent

Good

Fair

Poor

 

2.

Does the AIT know the regulatory resources governing nursing homes in California?

Yes

No

 

3.

Is the AIT ready to participate in the NHA licensure

examination?

 

Yes

No

 

4.

Does the AIT possess the knowledge, skills and ability to oversee/manage or direct a long term care facility?*

Yes

No

ADDITIONAL COMMENTS (Use additional paper if necessary):

This quarterly report has been verified and I/we certify under penalty of perjury that the information obtained is both true and correct.

Preceptor Signature

Date

AIT's Signature

Date

CDPH 501 (02/12)

Page 2 of 4

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

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

E G F P

B.WORK HABITS

1.Organizational 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

E G F P

C.QUALITY OF WORK

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

E G F P

CDPH 501 (02/12)

Page 3 of 4

 

 

AIT Name (Print):

 

 

 

 

E = EXCELLENT

G = GOOD

F = FAIR

P = POOR

 

 

 

 

 

 

 

 

 

 

 

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

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

E G F P

OVERALL RATING

E G F P

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 2.

CDPH 501 (02/12)

Page 4 of 4

How to Edit Form Cdph 501

We have applied the endeavours of the best developers to make the PDF editor you can use. Our application allows you to complete the ensures form easily and don’t waste precious time. What you need to undertake is follow these quick instructions.

Step 1: On the following website page, choose the orange "Get form now" button.

Step 2: At this point, you may edit the ensures. This multifunctional toolbar helps you include, erase, change, highlight, and also carry out many other commands to the words and phrases and areas within the document.

Feel free to enter the next details to complete the ensures PDF:

example of fields in Copes

Complete the Do you, Yes, If "no", Preceptor's Signature, Date, AIT's Signature, AIT #, Date, SECOND QUARTER - Total AIT, Start Date:, End Date:, Actual hours per week of, PROGRAM CHANGE(S) THIS QUARTER, Supporting documentation attached, and How would you rate the AIT's areas with any content which may be required by the program.

Filling out Copes step 2

In the THIRD QUARTER - Total AIT training, Start Date:, End Date:, Actual hours per week of, PROGRAM CHANGE(S) THIS QUARTER, AIT Name (Print):, Supporting documentation attached, How would you rate the AIT's, Excellent, Good, Fair, Poor, How many hours did you personally, Did anyone else assist the AIT, and Please list the training topics part, emphasize the important details.

Entering details in Copes step 3

Identify the rights and responsibilities of the parties within the paragraph Preceptor's Signature, Date, AIT's Signature, Date, FOURTH QUARTER - Total AIT, Start Date, End Date, PROGRAM CHANGE(S) THIS QUARTER, Actual hours per week of, Supporting documentation attached, How would you rate the AIT's, Excellent, Good, Fair, and Poor.

Copes Preceptor

End by looking at all these sections and completing them correspondingly: Yes, ADDITIONAL COMMENTS (Use, This quarterly report has been, Preceptor Signature, CDPH 501 (02/12), Date, AIT's Signature, Date, and Page 2 of 4.

Completing Copes step 5

Step 3: Click the button "Done". The PDF document can be exported. You may obtain it to your computer or send it by email.

Step 4: To avoid possible future complications, be sure you hold at the very least a few copies of every single form.

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