Instructor or Director of Staff Development Application
State of California ? Health and Human Services Agency
California Department of Public Health
INSTRUCTOR OR DIRECTOR OF STAFF DEVELOPMENT (DSD) APPLICATION
Submit this form and all supporting documents to TPRU@cdph. or fax to (916) 636-6760
Facility/School Information Facility/School Name
Telephone Number
Provider Identification Training Number(s) (if applicable)
Facility/School Mailing Address
Facility Licensed Bed
Type of Training to be Offered:
Capacity (SNF/ICF Only) Orientation and In-service Training
Nurse Assistant Training Program
Instructor/DSD Applicant Information
Instructor or DSD Number (if prior approval):
Applicant Name
Registered Nurse (RN) Licensed Vocational Nurse (LVN)
CA Nursing License Number
Applicant Mailing Address
Email Address
Telephone Number
Applicant Signature
Hours Employed as Instructor/DSD Date Employed as
Per week ______ Per month ______ Instructor/DSD _________
Submit the following: Resume showing verifiable work experience. Must include work experience in month/year to month/year format, name and address of each employer, job duties, contact telephone number for Human Resources or administration, and name of supervisor.
Active RN or LVN license in California.
Two (2) years of nursing experience (RN, LVN).
One (1) of the two years must be as a licensed nurse providing care and services to chronically ill or
elderly patients in an acute care hospital, skilled nursing facility, intermediate care facility, home care, hospice care, or other long-term care setting. AND one of the following:
One (1) year of experience planning, implementing, and evaluating educational programs in nursing.
OR Twenty-four (24) hours of continuing education in planning, implementing, and evaluating educational
programs in nursing (submit course certificate or transcript) completed within six (6) months of employment and prior to teaching a certification program. Courses must be approved by the Board of Registered Nursing or administered by an accredited educational institution.
By signing below, we attest that the applicant above meets the Instructor or DSD qualifications provided in Title 42 Code of Federal Regulations ?483.152, California Health & Safety Code ?1337.15, and California Code of Regulations, Title 22, ?71809, ?71821, ?71829, and 22 CCR ?75011.
Administrator/Owner Name (Print)
Director of Nursing/RN Program Director Name (Print)
Administrator/Owner Email Address
Director of Nursing/RN Program Director Email Address
Administrator/Owner Signature Instructor/DSD Approval Number:
Date
Director of Nursing/RN Program Director Signature
FOR DEPARTMENT USE ONLY
Date of Approval:
By TPRU Staff:
Date
CDPH 279 (11/2022) This form is available on our website: California Department of Public Health
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