Form Cdph 516 – Fill Out and Use This PDF

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

NHAP PRECEPTOR TRAINING

REGISTRATION FORM

SECTION I

NAME (Last)			(First)				(M.I.)	NHA LICENSE NUMBER
ADDRESS (Number and Street)			(City)				(State)	(Zip Code)
HOME TELEPHONE NUMBER			BUSINESS TELEPHONE NUMBER				SOCIAL SECURITY NUMBER*
(	)	-	(	)	-		___ ___ ___ — ___ ___ — ___ ___ ___ ___
FACILITY NAME			FACILITY TELEPHONE NUMBER				ADMINISTRATOR'S E-MAIL ADDRESS
			(	)	-
FACILITY ADDRESS (Number and Street)			(City)				(State)	(Zip Code)
SECTION II
Which address do you want your Preceptor correspondence sent to?					Home	Facility		Other (Complete below)

Which address/phone would you prefer to be on the Preceptor Public List?

Home

Facility

Other (Complete below)

SECTION III

CHECK APPROPRIATE BOX THAT SPECIFIES AT THE TIME OF THIS APPLICATION WHY YOU QUALIFY AS A PRECEPTOR DEFINED IN HEALTH AND SAFETY CODE 1416.57:

Have an active administrator license in California and have served at least two (2) years as the designated administrator of a licensed California nursing home. Not on probation, have no disciplinary actions pending, and the facilities overseen have/had a continuous operating history free from major deficiencies during my tenure.

Have an active administrator license in California and have served at least four (4) years as the designated Assistant Administrator of a licensed California nursing home. Not on probation, have no disciplinary actions pending, and the facilities overseen have/had a continuous operating history free from major deficiencies during my tenure.

SECTION IV

Since you last renewed your license, have you been convicted of or pled nolo contendere to any violation of any law in any state,	Yes	No
the United States or a foreign county? You must disclose all misdemeanor and felony convictions (including but not limited to
Civil, Welfare, Health and Safety, Vehicle, or Penal Code convictions) and any conviction that has been dismissed (under Section
1203.4 of the Penal Code.)

SECTION V

TRAINING SESSION YOU WISH TO ATTEND: Preceptor training date:

Select date from "Dates to Remember" flyer

REQUIRED INFORMATION TO ATTEND PRECEPTOR TRAINING

DID YOU REMEMBER TO:

Include check or money order for $100, payable to the Nursing Home Administrator Program (NHAP) ($75 certification fee and manual, and a $25 application fee.)

I understand that false or misleading answers are grounds for automatic denial of my application. I also understand that if my application is denied I will not be allowed to attend the preceptor training and NHAP will notify me in writing. All fees paid are non-refundable or non-transferable. I acknowledge that the foregoing information on this application is accurate, true and correct.

SIGNATURE OF APPLICANT		DATE
CDPH 516 (02/12)			Page 1 of 2

SECTION I Complete this section. All information requested is required.

SECTION II Complete this section. Indicate the specific address information.

SECTION III Check the appropriate box that qualifies you to participate in the training.

SECTION IV

Check the appropriate box indicating response for conviction statement and NHA Profile Sheet.

SECTION V Check the box indicating which training session you plan to attend. Sign and date the form.

REQUIRED INFORMATION

*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.

STATUTES THAT GOVEN THE NURSING HOME ADMINISTRATOR PROGRAM

Health and Safety Code, Section 1416, Nursing Home Administrator Program.

FOR OFFICE USE ONLY

Check/M.O. #:

Amount $:

NHAP STAFF INITIALS:

Issue Date:

Expiration Date:

Session Date:

CF#:

PRE#:

CE#:

CDPH 516 (02/12)

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