Form Cdph 502 PDF Details

The Department of Public Health (CDPH) has released a new form, CDPH 502, for reporting communicable diseases. The new form replaces the CDPH 1010 and is designed to be easier to use. Reported diseases will now be categorized into four groups: required, reportable, notifiable, and other conditions. The form can be submitted online or by mail. Healthcare providers are encouraged to submit reports as soon as possible in order to prevent further spread of disease. For more information on the new form or how to submit a report, visit the CDPH website.

Question	Answer
Form Name	Form Cdph 502
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	cdph502 ait program california form

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DATE SIGNED**

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
In this space, attach a recent									(916) 552-8780 FAX (916) 552-8777
In this space, attach a recent									NHAP@cdph.ca.gov
photo, sized approximately									NHAP@cdph.ca.gov
photo, sized approximately			APPLICATION FOR AIT PROGRAM
2" by 2", clearly picturing the			APPLICATION FOR AIT PROGRAM
applicant's face.	Return this completed form, with a check or money order for the application fee of $100, processing fee

(FOR IDENTIFICATION	of $25 and the fingerprint processing fee of $51 (Total $176)-(payable to NHAP) to the following
(FOR IDENTIFICATION	address:
PURPOSES ONLY)	address:
PURPOSES ONLY)			Nursing Home Administrators Program (NHAP)
			Nursing Home Administrators Program (NHAP)
						MS 3302
					P.O. Box 997416
			Sacramento, CA 95899-7416

APPLICANT'S NAME (Last)			(First)				(M.I.)	SOCIAL SECURITY NUMBER*
								___ ___ ___ — ___ ___ — ___ ___ ___ ___

MAILING ADDRESS (Number)		(Street)						WORK TELEPHONE NUMBER
								(	)	-

(City)		(County)		(State)		(Zip Code)		HOME TELEPHONE NUMBER
								(	)	-

E-MAIL ADDRESS (Optional)			FAX NUMBER (Optional)					DATE OF BIRTH

___ ___ / ___ ___ / ___ ___ ___ ___

*Social Security Number Disclosure: Pursuant to Section 666(a)(13) of Title 42 of the United States Code and California Family Code, Section 17520, Subdivision (d), the California Department of Public Health (CDPH) is required to collect social security numbers from all applicants for nursing home administrator licenses. Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child support orders upon request by the Department of Child Support Services and for reporting disciplinary actions to the Health Integrity and Protection Data Bank as required by 45 CFR, Section 61.1 et seq. Failure to provide your social security number will result in the return of your application. Your social security number will be used by CDPH for internal identification, and may be used to verify information on your application, to verify certification with another state's certification authority, for exam identification, for identification purposes in national disciplinary databases or as the basis of a disciplinary action against you.

ANSWER THE FOLLOWING QUESTIONS:

1.Are you a United States Citizen or a legal resident?

2.Are you at least eighteen (18) years of ago or older?

3.Are you now, or were you, employed as a Nursing Home Administrator? (If "Yes", fill in the information below.)

State:

License #:

Date of Expiration:

Yes	No
Yes	No
Yes	No

4. Former Names? (If "Yes", list in space below)	Yes	No
a.

b.

c.

5. Have you ever pled guilty or nolo contendere to, or been convicted of, any crime (other than minor traffic violations)?	Yes	No

IF THE ANSWER TO THIS QUESTION IS "YES", EXPLAIN FULLY ON A SEPARATE SHEET OF PAPER. PROVIDE CERTIFIED COPIES OF ARREST REPORT AND COURT DOCUMENTS THAT INCLUDE THE FOLLOWING, AS APPLICABLE: CRIMINAL COMPLAINT, PLEA AND JUDGEMENT, AND PROBATION REPORT. IF THESE RECORDS HAVE BEEN DESTROYED, THE PROGRAM REQUIRES A SIGNED STATEMENT TO THAT FACT ON AGENY LETTERHEAD; FROM THE AGENCY YOU ARE REQUESTING RECORDS. A CONVICTION WILL NOT NECESSARILY DISQUALIFY YOU.

6. Are you now or have you ever been licensed or certified by any other California state agency? (If "Yes", please complete below.)			Yes	No
Agency:	License #:	Date of expiration:
Agency:	License #:	Date of expiration:
Agency:	License #:	Date of expiration:
Agency:	License #:	Date of expiration:

**CERTIFICATION -- IMPORTANT -- PLEASE READ BEFORE SIGNING--If not signed, this application may be rejected.

I certify under the penalty of the perjury law of the State of California that the information I have entered on this application (pg. 1-4) is true and correct. I further understand that any false incomplete, or incorrect statements may result in denial of this AIT application and/or disqualification of the applicant's AIT hours with the Nursing Home Administrator Program. I authorize the employers and educational institutions identified on this application to release any information they may have concerning my employment or education to the State of California Nursing Home Administrator Program.

APPLICANT'S SIGNATURE**

APPLICANTS--DO NOT USE THIS SPACE BELOW--FOR NHAP USE ONLY

CASH #

NHAP INITIALS

AMOUNT

FOR NHAP OFFICE USE ONLY

STATUS

Approved	Rejected			Denied

Unopened Trascripts			Training Outline

Fingerprints			AIT#	Preceptor Approved

STAFF		DATE PROCESSED

CDPH 502 (02/12)

Page 1 of 4

APPLICANT'S NAME (Last)

(First)

(M.I.) SOCIAL SECURITY NUMBER*

___ ___ ___ — ___ ___ — ___ ___ ___ ___

7. EDUCATION

DID YOU GRADUATE FROM HIGH SCHOOL? IF NOT, DID YOU POSSESS A GED OR EQUIVALENT? IF NOT, ENTER THE HIGHEST GRADE YOU COMPLETED?

Yes

UNIVERSITY OR COLLEGE NAME-AND LOCATION.

BUSINESS, CORRESPONDENCE, TRADE,

TECHNICAL, OR SERVICE SCHOOL

COURSE OF STUDY

UNITS COMPLETED		DIPLOMA, DEGREE OR	DATE
		DIPLOMA, DEGREE OR	DATE
SEMESTER	QUARTER	CERTIFICATE OBTAINED	COMPLETED

8. You are applying for the AIT program on the basis of: (check only one):

Baccalaureate or higher degree, complete only sections 9 and 11 of this application.

Ten (10) years of recent full-time work experience, as a registered nurse in a nursing home with at least the most recent five (5) of the ten (10) years of work experience in a supervisory position, complete only sections 10 and 11 of this application.

Ten (10) years of full-time work experience, in any department of nursing home, with at least the most recent five (5) of the ten (10) years of work experience in a supervisory position, and sixty (60) semester units (or ninety (90) quarter units) of college or university courses, complete only

sections 10 and 11 of this application.

9.EMPLOYEMENT HISTORY--Begin with your most recent job. List each position separately.

FROM (MM/DD/YY)	TO (MM/DD/YY)	JOB TITLE/CLASSIFICATION

HOURS PER WEEK	TOTAL WORKED (Year/Months)	EMPLOYER NAME

TYPE OF BUSINESS			ADDRESS, CITY, STATE, ZIP

DUTIES AND RESPONSIBILITIES

FROM (MM/DD/YY)	TO (MM/DD/YY)	JOB TITLE/CLASSIFICATION

HOURS PER WEEK	TOTAL WORKED (Year/Months)	EMPLOYER NAME

TYPE OF BUSINESS			ADDRESS, CITY, STATE, ZIP

DUTIES AND RESPONSIBILITIES

CDPH 502 (02/12)

Page 2 of 4

APPLICANT'S NAME (Last)

(First)

(M.I.)

SOCIAL SECURITY NUMBER*

___ ___ ___ — ___ ___ — ___ ___ ___ ___

9. EMPLOYEMENT HISTORY (Continued)

FROM (MM/DD/YY)

TO (MM/DD/YY)

JOB TITLE/CLASSIFICATION

HOURS PER WEEK

TOTAL WORKED (Year/Months) EMPLOYER NAME

TYPE OF BUSINESS

ADDRESS, CITY, STATE, ZIP

DUTIES AND RESPONSIBILITIES

10.NURSING HOME WORK EXPERIENCE (Licensed NHAs, RNs and Physicians. Ten (10) years work experience required.)

FROM (MM/DD/YY)	TO (MM/DD/YY)	JOB TITLE/CLASSIFICATION
HOURS PER WEEK	TOTAL WORKED (Year/Months)	FACILITY NAME

SUPERVISORY?

YES NO

DEPARTMENT OF NURSING HOME

FACILITY ADDRESS, CITY, STATE, ZIP

DUTIES AND RESPONSIBILITIES

CHECK APPROPROATE BOX

I am authorized and have personally verified the information from records on file at the facility	FROM:	/	/	TO:	/	/

I have personal knowledge of this work experience because I worked at the same facility as the applicant	FROM:	/	/	TO:	/	/

** Signature of licensed NHA, Physician, or RN	LIC.#:			DATE:	/	/

FROM (MM/DD/YY)	TO (MM/DD/YY)	JOB TITLE/CLASSIFICATION
HOURS PER WEEK	TOTAL WORKED (Year/Months)	FACILITY NAME

SUPERVISORY?

YES NO

DEPARTMENT OF NURSING HOME

FACILITY ADDRESS, CITY, STATE, ZIP

DUTIES AND RESPONSIBILITIES

CHECK APPROPROATE BOX

I am authorized and have personally verified the information from records on file at the facility	FROM:	/	/	TO:	/	/

I have personal knowledge of this work experience because I worked at the same facility as the applicant	FROM:	/	/	TO:	/	/

** Signature of licensed NHA, Physician, or RN	LIC.#:			DATE:	/	/

CDPH 502 (02/12)

Page 3 of 4

APPLICANT'S NAME (Last)

(First)

(M.I.) SOCIAL SECURITY NUMBER*

___ ___ ___ — ___ ___ — ___ ___ ___ ___

10.NURSING HOME WORK EXPERIENCE (Licensed NHAs, RNs and Physicians. Ten (10) years work experience required.)

FROM (MM/DD/YY)	TO (MM/DD/YY)	JOB TITLE/CLASSIFICATION
HOURS PER WEEK	TOTAL WORKED (Year/Months)	FACILITY NAME

SUPERVISORY?

YES NO

DEPARTMENT OF NURSING HOME

FACILITY ADDRESS, CITY, STATE, ZIP

DUTIES AND RESPONSIBILITIES

CHECK APPROPROATE BOX

I am authorized and have personally verified the information from records on file at the facility	FROM:	/	/	TO:	/	/

I have personal knowledge of this work experience because I worked at the same facility as the applicant	FROM:	/	/	TO:	/	/

** Signature of licensed NHA, Physician, or RN	LIC.#:			DATE:	/	/

11. PRECEPTOR INFORMATION -- TO BE COMPLETED BY PRECEPTOR

PRECEPTOR NAME (Last)		(First)			(Middle)

NHA LICENSE NUMBER	NHA LICENSE EXPIRATION DATE		PRECEPTOR NUMBER	PRECEPTOR EXPIRATION DATE

PRECEPTOR 'S PRINCIPAL JOB(S)/TITLE(S)

NAME OF FACILTY, OFFICE OR CORPORATION

TELEPHONE NUMBER

(

)

ADDRESS OF FACILTY, OFFICE OR CORPORATION (Number and Street)

(City)

(State)	(Zip Code)

NAME OF SNF/ICF WHERE TRAINING WILL TAKE PLACE

TELEPHONE NUMBER

(

)

ADDRESS OF SNF/ICF WHERE TRAINING WILL TAKE PLACE (Number and Street)

(City)

(State) (Zip Code)

NUMBER OF HOURS PER WEEK AIT WILL BE TRAINING

NUMBER OF HOURS PER WEEK YOU, AS THE PRECEPTOR, WILL BE PERSONALLY SUPERVISING THE TRAINING OF THE AIT

Minimum 20

Maximum 60

Other

I have reviewed the application package and it is complete with necessary attachments listed below.

2 X 2 Photo	$25 Processing Fee	Criminal Conviction Documentation
Unopened Transcript(s)	$51 Criminal Record Check Fee
1,000 Hour AIT Outline	$100 Application Fee

I declare under penalty of perjury under the laws of the State of California that the information furnished in section 11 is true and correct. I hereby agree to make it my personal responsibility to see that the Administrator-In-Training (AIT) receives the type and amount of training required to make him/her fully qualified to become a licensed Nursing Home Administrator. I will comply with all the requirements of the AIT program, as set forth in the rules and regulations of the State Nursing Home Administrator Program (Health and Safety Code, Chapter 2.35). I understand that failure to supervise the AIT as indicated above will result in the AIT's training hours being disqualified and may result in suspension of my California Preceptor certificate.

PRECEPTOR SIGNATURE

DATE

CDPH 502 (02/12)

Page 4 of 4

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
	Fax: (916) 552-8777

(For Statistical Use Only)

APPLICANT: To assist NHAP in creating applicant statistical information, applicants are asked to voluntarily provide the following information. This questionnaire will be separated from the application prior to its review and will be kept confidential. Government Code Section 19705 authorizes the State to retain this information for research and statistical purposes.

AGE
(1) UNDER 21	(3) 21-39	(6) 40-69	(7) 70 AND OVER

GENDER

MALE FEMALE

EthNic Category (Please check the box that best describes your race/ethnicity):

(7)AMERICAN INDIAN OR ALASKAN NATIVE-- Persons having origins in any of the tribal people of North America, and who maintain cultural identification through tribal affiliation or community recognition.

(2)ASIAN-- Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent. This includes China, Japan, and Korea.

(1)	AFRICAN AMERICAN-- Persons having origins in any of the black racial groups.

(8)	FILIPINO-- Persons having origins in any of the original peoples of the Philippine Islands.

(4)HISPANIC-- Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

(6)	PACIFIC ISLANDERS-- Persons having origins in the Pacific Islands, such as Samoa.

(5)	CAUCASIAN-- Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Check if:

(3)	OTHER (Specify):

(Y)	DISABLED-- A person with a disability is an individual who: (1) has a physical or mental impairment that substantially limits one or
	more life activities, such as walking, speaking, breathing, performing manual tasks, seeing, hearing, learning, caring for oneself or
	working; (2) has a record of such an impairment; (3) is regarded as having such an impairment.
	MILITARY-- A military veteran; a widow or widower of a veteran; or a spouse of a 100% disabled veteran.

Why did you enter the AIT program?

PRECEPTOR OR NHA	EDUCATION/BACKGROUND IN LONG TERM CARE
OWN A NURSING HOME	OTHER:

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE

CDPH 502 (02/12)

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1. The Form Cdph 502 usually requires particular details to be entered. Be sure that the next fields are filled out:

2. Just after performing the last step, go to the next stage and fill in the essential details in these blank fields - Agency Agency Agency, License License License, Date of expiration Date of, CERTIFICATION IMPORTANT PLEASE, I certify under penalty of the, APPLICANTS SIGNATURE, DATE, APPLICANTS DO NOT USE THE SPACE, CASH, NHAP INITIALS, AMOUNT, CDPH, STATUS, Approved, and Rejected.

3. This next segment is usually quite easy, APPLICANTS NAME Last, First, SOCIAL SECURITY NUMBER, EDUCATION, DID YOU GRADUATE FROM HIGH SCHOOL, Yes, UNIVERSITY OR COLLEGE NAMEAND, LOCATION BUSINESS CORRESPONDENCE, IF NOT DO YOU POSSESS A GED OR, IF NOT ENTER THE HIGHEST GRADE YOU, Yes, COURSE, UNITS, SEMESTER, and QUARTER - these form fields is required to be filled out here.

Form Cdph 502 completion process detailed (stage 3)

4. The next part will require your input in the subsequent places: DUTIES AND RESPONSIBILITIES, FROM MMDDYY, TO MMDDYY, JOB TITLECLASSIFICATION, HOURS PER WEEK, TOTAL WORKED YearsMonths, FACILITY NAME, DEPARTMENT OF NURSING HOME, FACILITY ADDRESS CITY STATE ZIP, and DUTIES AND RESPONSIBILITIES. Make certain to enter all required details to move forward.

Part no. 4 for filling out Form Cdph 502

Lots of people frequently make some mistakes when completing FACILITY ADDRESS CITY STATE ZIP in this section. Remember to review whatever you enter here.

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Form Cdph 502 completion process detailed (part 5)

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