Form Il462 1292 PDF Details

Illinois Form Il462 1292 is a residential real estate contract. The form is used to create a legally binding agreement between the buyer and the seller of a property. The form includes information about the purchase price, the closing date, and other important details about the sale. It is important to review this form carefully before signing it to ensure that you understand all of the terms and conditions. If you have any questions, be sure to discuss them with your attorney prior to signing. By signing this form, you are agreeing to be bound by its terms and conditions. Thank you for reading! I hope this was helpful :)

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

Form Preview Example

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

2

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.

3

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.

4

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

5

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)

6

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

Page 1 of 1

How to Edit Form Il462 1292 Online for Free

Form Il462 1292 can be filled in without difficulty. Just try FormsPal PDF editing tool to perform the job in a timely fashion. Our development team is always working to develop the editor and ensure it is even easier for users with its extensive features. Uncover an endlessly innovative experience today - explore and find out new possibilities along the way! To get the ball rolling, go through these basic steps:

Step 1: Click the "Get Form" button above. It'll open up our pdf editor so that you can begin filling in your form.

Step 2: The editor offers you the capability to modify your PDF document in a range of ways. Transform it by writing any text, correct what's originally in the file, and place in a signature - all when it's needed!

Completing this form will require thoroughness. Ensure that all mandatory blank fields are completed correctly.

1. Complete your Form Il462 1292 with a number of major blank fields. Consider all the necessary information and make certain absolutely nothing is missed!

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

5. To wrap up your document, this last section involves some extra blank fields. Filling out Tel Fax Email dspemailsiuedu, and June will certainly conclude everything and you're going to be done before you know it!

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

It is easy to make an error when filling out your Tel Fax Email dspemailsiuedu, for that reason make sure you go through it again before you send it in.

Step 3: Spell-check all the details you've inserted in the blanks and press the "Done" button. Go for a 7-day free trial subscription at FormsPal and obtain immediate access to Form Il462 1292 - downloadable, emailable, and editable from your FormsPal account. We do not sell or share any information you type in when working with forms at FormsPal.

Form Il462 1292 isn’t the one you’re looking for?

Related Documents