Form Il462 1292 PDF Details

The Il462 1292 form stands as a critical component in the process of credentialing Direct Support Personnel (DSP) within the Illinois healthcare system, aimed at ensuring that individuals tasked with the direct support of individuals with developmental disabilities are appropriately trained and registered. Developed by the Illinois Department of Human Services’ Division of Developmental Disabilities, this form facilitates the submission of DSP training completion to the Illinois Health Care Worker Registry. The instruction manual delineates a step-by-step guide to accurately complete and submit this form online, a transformation from the now obsolete Scranton Form, within a specified timeframe—ideally within 30 days following the completion of 120 hours of state-approved DSP training. Failure to comply with this timeframe requires a Waiver Letter from the Department, underscoring the form's role not only as an administrative necessity but also as a measure to uphold stringent training standards. The manual comprehensively covers essential aspects from when to submit the DSP Training Registry Packet to detailing how personal and program-specific information should be filled out, including obligatory details like the DSP's name, Social Security Number, and training completion date, alongside optional personal descriptors. Furthermore, it elucidates the process for online submission, which underscores the digital transformation in administrative practices aimed at streamlining processes and ensuring timely updates to the Health Care Worker Registry. This move towards digital submissions, facilitated through a dedicated DSP Online Registry Website, underscores a broader trend towards leveraging technology to enhance efficiency, accuracy, and accessibility in healthcare workforce credentialing.

QuestionAnswer
Form NameForm Il462 1292
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesHCW Application Form direct support person verification form

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DIRECT SUPPORT PERSON (DSP) TRAINING ILLINOIS HEALTH CARE WORKER REGISTRY

INSTRUCTION MANUAL

JUNE

2012

THIS BOOKLET INCLUDES STEP-BY-STEP

INSTRUCTIONS FOR SUBMITTING DSP TRAINING TO

THE ILLINOIS HEALTH CARE WORKER REGISTRY

Illinois Department of Human Services

Division of Developmental Disabilities

319 E. Madison Street, Suite 4J

Springfield, IL 62701

DIRECT SUPPORT PERSON (DSP) TRAINING

ILLINOIS HEALTHCARE REGISTRY

INSTRUCTION MANUAL

TABLE OF CONTENTS

WHEN TO SUBMIT DSP TRAINING REGISTRY PACKET………………………………….3

COMPLETING THE DSP REGISTRY FORM……………………….……………....………….3

SUBMITTING THE DSP REGISTRY FORM ONLINE …………..……………………………5

ILLINOIS HEALTH CARE WORKER REGISTRY FOLLOW UP CHECK…..……………….6

ILLINOIS HEALTH CARE WORKER REGISTRY APPLICATION FORM…………………..7

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June 2012

 

WHEN TO SUBMIT THE DSP TRAINING REGISTRY PACKET

A DSP Training record should be submitted to the Illinois Health Care Worker Registry when the DSP has successfully completed 120 hours of DSP training

from a training program that has been approved by the Illinois Department

of Human Services. The Illinois Health Care Worker Registry Application Form,

referred to in this Instruction Manual as the DSP Registry Form, must be

completed accurately and submitted online to SIU within 30 days of the DSP training completion date for each DSP.

DSP Registry Forms completed after 30 days following the successful completion of the 120 hours of DSP training will not be accepted by the SIU online system without a Waiver Letter from the Department of Human Services (DHS) waiving this State of Illinois training requirement. More information about DSP Waivers for Delays in Meeting Training Requirements is available on the DHS website.

COMPLETING THE DSP REGISTRY FORM

The Illinois Health Care Worker Registry Application Form (DSP Registry Form) replaces the Scranton Form used previously to report DSP training completion.

Scranton forms are no longer accepted by SIU.

Follow the completion directions on the Illinois Health Care Worker Registry Application Form before entering the information in the SIU online system. All required Applicant information MUST be provided on this form. The fields are identified below:

REQUIRED INFORMATION

Name

Enter the DSP’s last name, first name, and middle name (if applicable). Please make sure the names entered here match the ones used by the trainee to request an Illinois State Police fingerprint criminal background check.

Date of Birth

Enter the month, the date, and the year the DSP was born.

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June 2012

 

Social Security Number

Enter the DSP’s Social Security Number (SSN) in the spaces provided. This number is used as the unique identifier for person’s reported on the Illinois Health Care Worker Registry. Please make sure the SSN is correct and matches the SSN used by the trainee to request an Illinois State Police fingerprint criminal background check.

COMPLETING THE DSP REGISTRY FORM (continued)

Address

Enter the DSP’s complete street address, apartment number (if applicable), city, state, and 5- digit zip code where the DSP receives mail.

Telephone Number

Enter the telephone number where the DSP can be reached during the day.

Program Code

Enter the agency’s 4–digit program code. If you do not know this code, please call 217-782-9438.

Program Completion Date

Enter the month, day, and year the DSP successfully completed the 120 hours of DSP training. The month, day and year must be the same as the date reported on the DSP Core Competency Area Checklist (IL 462-1286) or Direct Support Person Training Program: Core Competency Verification (IL 462-1290).

OPTIONAL INFORMATION

Race

Check the box that identifies the Race of the DSP.

Sex

Check the box that identifies the Sex of the DSP.

Eye Color

Check the box that identifies the eye color of the DSP.

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June 2012

 

Height

Enter the height of the DSP in feet and inches.

Consent to Place Information on Registry - Signature

The DSP’s signature on this form certifies that the information provided by the DSP is accurate and grants permission to the State of Illinois and any affiliate on behalf of the State of Illinois to place information from the form onto the Illinois Health Care Worker Registry.

SUBMITTING THE DSP REGISTRY FORM ONLINE

All Illinois Department of Human Services (IDHS) provider agencies with a DSP training program approved by the IDHS are eligible to submit DSP Registry Forms (Illinois Health Care Worker Registry Application Form) for their DSPs online.

The DSP Online Registry Website:

https://dspr.dxrgroup.com

Request for login credentials

If you do not have your login credentials, please call 618-453-1962 or email dsp.email@siu.edu to request one.

Inquiry by Mail, Telephone, Fax, or Email

Illinois Nurse Assistant/Aide Training

Competency Evaluation Program

DSP Training Project

Southern Illinois University

Mail Code 4340

Carbondale, IL 62901

Tel: 618-453-1962

Fax: 618-453-4300

Email: dsp.email@siu.edu

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June 2012

 

NOTE: Southern Illinois University does not process reimbursements. DSP Training Reimbursement information may be found in the Bureau of Community Reimbursement’s Staff Training Reimbursement and Billing Manual on the DHS website.

If you have questions regarding reimbursement, please call 217-557-7673. Requests for reimbursement should be mailed to the following address:

Illinois Department of Human Services

Bureau of Community Reimbursement Unit

319 E. Madison, Suite 2K

Springfield, IL 62701

Attn: Shaun Tobin

ILLINOIS HEALTH CARE WORKER REGISTRY FOLLOW UP CHECK

After submitting an online DSP Registry Forms to Southern Illinois University, allow 3 working days for processing, and then check the Health Care Worker Registry to ensure that the DSP’s name appears on the Registry with the designation “DD Aide” under Programs. The Health Care Worker Registry is on the Illinois Department of Public Health website or providers can check by calling the Illinois Department of Public Health’s Nurse Aide Registry at 217-785-5133.

NOTE: Section 350.683 c. of the Illinois Administrative Code requires that an individual shall notify the Health Care Worker Registry of CHANGES IN NAME OR ADDRESS WITHIN 30 DAYS and SUBMIT PROOF OF ANY NAME CHANGE TO THE DEPARTMENT. (Section 3-206.01 of the Act)

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June 2012

 

State of Illinois Department of Human Services

Division of Developmental Disabilities

ILLINOIS HEALTH CARE WORKER REGISTRY APPLICATION FORM

(Please type or print legibly)

Applicant Information

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First

 

 

 

 

 

 

Middle

Date of Birth:

 

 

 

 

 

 

 

 

 

 

Social Security Number:

-

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month / Day / Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address / P.O. Box / Rural Route

 

 

 

 

 

 

 

 

 

 

Apt.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

 

 

Zip Code

Telephone Number:

 

 

 

 

 

-

 

 

-

 

 

 

 

 

Program Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Program Completion Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month / Day / Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Optional Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race

Asian / Pacific Islander

 

 

 

 

American Indian / Alaskan Native

 

 

 

 

 

 

White

 

 

 

 

 

 

 

 

Black

 

 

Unknown

Sex

Male

 

 

 

 

 

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

Eye Color

Blue

 

 

 

 

 

 

 

 

Green

 

 

Brown

 

 

 

 

 

 

Hazel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height

(feet)

(inches)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Consent to Place Information on Registry

Your signature on this application certifies that the information provided is accurate and grants permission to the State of Illinois and any affiliate acting on the behalf of the State of Illinois to place information from this form on the Illinois Care Worker Registry.

Signature

IL462-1292 (N-6-12) Illinois Health Care Worker Registry Application Form

 

Printed by Authority of the State of Illinois 0 Copies

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Completing section 1 in Form Il462 1292

2. Once your current task is complete, take the next step – fill out all of these fields - Follow the completion directions, REQUIRED INFORMATION, Name, Enter the DSPs last name first, Date of Birth, Enter the month the date and the, and June with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Filling in part 2 in Form Il462 1292

3. Completing Enter the month day and year the, OPTIONAL INFORMATION, Race, Check the box that identifies the, Sex, Check the box that identifies the, Eye Color, and Check the box that identifies the is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Form Il462 1292 completion process outlined (part 3)

4. To move onward, the next part involves filling in a few fields. These comprise of All Illinois Department of Human, The DSP Online Registry Website, httpsdsprdxrgroupcom, Request for login credentials, If you do not have your login, Inquiry by Mail Telephone Fax or, and Illinois Nurse AssistantAide, which you'll find essential to moving forward with this form.

The right way to fill in Form Il462 1292 stage 4

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Tel Fax Email dspemailsiuedu, June, and June inside Form Il462 1292

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