Follow the steps to successfully complete the Cdph 279 form online.

1. Press the ‘Get Form’ button to access the Cdph 279 document and open it in your preferred online environment.
2. Begin by entering the facility, school, or agency’s telephone number and county in the designated fields.
3. Fill in the Provider Identification Training Number, which is either an ‘S’ or ‘F’ number, as required.
4. Complete the section detailing the facility, school, or agency name, along with the full address.
5. Indicate the type of training to be offered by selecting one of the options: Orientation and In-Service Training Programs only, Certification Training Program only, or Orientation, In-Service, and Certification Training Programs.
6. Input the applicant’s name and select the appropriate nursing title: Registered Nurse (RN) or Licensed Vocational Nurse.
7. Specify the hours employed per week and the date employed as a director of staff development or instructor.
8. Provide the California nursing license number along with its expiration date.
9. If applicable, enter the licensed bed capacity of the facility.
10. Record the date the application is submitted to CDPH.
11. List the accompanying documents required for submission, including a resume detailing work experience, proof of completion of the 24-hour BRN approved DSD class or related college courses, and a copy of the active nursing license.
12. Fill in the facility, school, or agency information, including the name, telephone number, mailing address, city, county, and zip code.
13. Obtain signatures from the administrator or program director, including their printed names and dates.
14. Ensure the director of nursing also provides their signature, printed name, and date.
15. Once all fields are completed, review the form, save any changes, download a copy for your records, and print or share it as necessary.

Complete your Cdph 279 form online today for a seamless application process!