Appendix 3 - New York State Department of Health
INSTRUCTIONS:
1. Complete all questions/areas in the application.
2. Label attachments with the question number that it addresses.
3. Submit application, documents requested, and supporting documentation for any proposed changes that have NOT been approved by the Department to the Regional Office Home Care Program Manager.
AGENCY NAME: _________________________________________________________________
AGENCY ADDRESS: ______________________________________________________________
OPERATING CERTIFICATE/LICENSE #: _______________________________________________
PREVIOUS APPROVAL DATES: _______________________________________________________
OPERATOR CERTIFICATION STATEMENT
Misrepresentation or falsification of any information contained in this application may be punishable by fine and/or imprisonment under New York State law and Federal law and may result in immediate program disapproval.
The training program must abide by all Home Health Aide Training Program and Home Care Registry requirements and guidelines set forth by the Department.
I hereby certify that I have read the above statements and that the information furnished in this Home Health Aide Training Program Re-approval Application is true and correct to the best of my knowledge.
SIGNATURE DATE
Print Name and Title:
Person to be contacted related to information contained in the application:
Name: PHONE NUMBER: ( )
E-mail:
1. Has the curriculum changed since last approval? No Yes
Attach changes or indicate DOH curriculum Approval Date: _______________
2. Name of Textbook, Publisher, and Edition (must be approved by the Department):
__________________________________________________________________________________
3. How does the student/aide receive his/her certificate?
Aide/student picks up Certificate is mailed Other (specify)
4. List current contracts for Supervised Practical Training (SPT). Attach additional sheets if needed.
Note: Nursing homes may not be used as SPT locations.
5. Attach past 3 years of HHATP Annual Program Evaluations.
6. Attach Policy and Procedure describing the quality management program for the HHATP.
FOR DEPARTMENT USE ONLY:
DATE OF RECEIPT OF APPLICATION: __________/__________/__________
REQUEST FOR ADDITIONAL INFORMATION/CLARIFICATION:
DATE OF REQUEST: __________/__________/__________
DATE ADDITIONAL INFORMATION RECEIVED: __________/__________/__________
APPROVAL:
DATE OF TRAINING PROGRAM APPROVAL: __________/__________/__________
REVIEWED BY: _____________________________________________________________
DATE OF DOH RESPONSE: __________/__________/__________
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