Form Cdph 516 PDF Details

Form CDPH 516 is an important document that all California employers must complete in order to be in compliance with the state's health and safety regulations. This form is used to report any workplace injuries or illnesses that have occurred, and it is due on a monthly basis. Failing to complete and submit this form can lead to serious penalties, so it's important to know what information needs to be included. In this blog post, we'll provide a detailed overview of Form CDPH 516, including what information needs to be included and how to submit it. We'll also highlight some of the consequences for failing to comply with state health and safety regulations. So if you're an employer in California, make sure you read this post!

QuestionAnswer
Form NameForm Cdph 516
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfalse, California, cdph nursing home administrator program, nursing home administrator preceptor california

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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)

ADDRESS (Number and Street)

(City)

(State) (Zip Code)

TELEPHONE NUMBER

(

)

-

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

Home

Facility

Other (Complete below)

ADDRESS (Number and Street)

(City)

(State) (Zip Code)

TELEPHONE NUMBER

(

)

-

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)

 

 

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Please submit Preceptor Training Registration form with a check or money order of $100, (payable to NHAP) on or before the final filing
date to:NHAP MS 3302
P.O. Box 997416
Sacramento, CA 95899-7416
HOW TO COMPLETE THE APPLICATION FOR PRECEPTOR TRAINING

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.

.

.

.

IMPORTANT INFORMATION

Registration and fee must be postmarked by final filling dates for processing (see Section V). Applications received after the postmarked date will be denied. Fees submitted are non-refundable and non-transferrable.

Six (6) hours of continuing education credit will be granted for attending the Preceptor Training.

Preceptor certificates must be renewed every three (3) years from issuance date.

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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