Form Dshs 14 371 – Fill Out and Use This PDF

Form Dshs 14 371 is a form officially accepted by the Washington State Department of Social Health Services. This document is important for seeking eligibility for a number of benefits and programs, such as cash or medical assistance, or to let know that changes have taken place in your scenario. Along with this form, additional documents may be necessary to prove that you meet the requirements included in accurate eligibility categories set by DSHS. Providing the appropriate documentation ensures a swift evaluation process of your application through DSHS.

Form Dshs 14 371 PDF Details

Form DSHS 14 371, also known as the “Food Stamp Application” is a form that is used to apply for food stamps in the state of Washington. The form can be completed online or through a paper application, and it requires basic information about the applicant, such as their name, address, and Social Security number. The form also asks questions about the household’s income and assets, as well as how many people are in the household. Completing this form is the first step in applying for food stamps in Washington. Form DSHS 14 371 is also known as the "Food Stamp Application." It's a form used to apply for food stamps in Washington State. The form can be completed online or through a paper application. Itrequires information about you such as your name, address and social security number; andinformation about your household's income and assets- plus how many members are in yourhousehold. Completing this form is just one step of applying for food stamps here inWashington State!

Question	Answer
Form Name	Form Dshs 14 371
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	14_371 natcep arizona form

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AGING AND LONG-TERM SUPPORT ADMINISTRATION OMMIBUS	DEPARTMENT OF HEALTH
BUDGET RECONCILIATION PROGRAM	NURSING ASSISTANT TRAINING
PO BOX 45600 OLYMPIA WA 98504-5600	PROGRAM
FAX 360-493-2581	PO BOX 47852 OLYMPIA, WA 98504-7852
	FAX 360-236-2901

Nursing Assistant Training Program (NATCEP)

Application for Approval

DATE OF APPLICATION

LEGAL NAME OF SPONSORING HEALTH CARE FACILITY, HOSPITAL, SCHOOL OR OTHER ENTITY				PHONE NUMBER (WITH AREA CODE)

BUSINESS ADDRESS	CITY		COUNTY	STATE	ZIP CODE

STREET ADDRESS IF DIFFERENT FROM MAILING ADDRESS		CITY		STATE	ZIP CODE

E-MAIL ADDRESS

NAME OF FACILITY ADMINISTRATOR, VOCATIONAL DIRECTOR, DEPARTMENT HEAD OR CHEIF ADMINISTRATIVE OFFICER

NAME OF PROGRAM DIRECTOR, NURSING ASSISTANT TRAINING PROGRAM			CONTACT PHONE NUNBER (WITH AREA CODE)

Describe the classroom space allotted to your training program. Specify type of room, square footage, self-contained or shared space, room equipment and classroom furniture, square footage, maximum number of students that can be comfortably accommodated, other uses of this room during non-class time and the availability / location of teaching materials and audio-visual equipment. Attach a separate sheet if necessary. Is this classroom off-site, that is, located elsewhere from the street address listed above? Yes No

Describe the training laboratory and the personal care equipment used for the practice of clinical skills. Attach a separate sheet if necessary.

List the teaching resources for the program. For example, name and publication date of textbooks and audio-visual equipment.

Textbooks:

Audio-visuals:

Other (specify):


Number of hours proposed for your Nursing Assistant Training
Program:				Total hours:
Classroom
Clinical
How many clinical hours will be in the facility?
How many clinical hours will be in the lab setting?

Important: Please read Page 2 of this form.

DSHS 14-371 (REV. 05/2012)

Nursing Assistant Training Program (NATCEP) Application Approval, Page 2

LIST ALL INSTRUCTORS

LIST ALL FACILITIES WHERE CLINICAL TRAINING WILL BE CONDUCTED THROUGH YOUR TRAINING PROGRAM

The following attachments are required for all programs. ATTACH THE FOLLOWING TO THIS APPLICATION.

1. NATCEP Application for Program Director, DSHS 14-370

2. Declaration of the Program Director, DSHS 09-961

3. Instructional Staff Applications, DSHS 14-369. This is not applicable if the program director is the sole instructor.

4. A list of course objectives for your training program.

5. The curriculum outline and schedule of class and clinical presentations. The applicant must provide evidence of content that will lead to the achievement of all required nursing assistant competencies listed in Washington Administrative Code (WAC) 246-841 and 42CFR 483-152.

6. A sample lesson plan for one core unit of the curriculum outline. This includes a lesson plan objective and any supporting sub-objectives.

7. The skills checklist used in your program for skills achievement verification.

8. A description of the evaluation methods and your program requirements for passing. Describe below or use a separate sheet.

9. Copies of the required affiliated agreement with facilities where clinical training is conducted. (Non-facility based programs only)

10. Sample of student record form to be used by training program.

11. Non-facility based programs must verify that the nursing assistant training school is approved to operate in the state of Washington by:

a.The State Board for Community and Technical Colleges;

b.The Superintendent of Public Instruction; or

c.The Workforce Training and Education Coordinating Board.

DSHS 14-371 (REV. 05/2012)

Form Dshs 14 371 – Fill Out and Use This PDF

Form Dshs 14 371 PDF Details

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