Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the name of the direct care staff in the designated field at the top of the form.
3. Enter the name and address of the facility where the staff member works. Be thorough and ensure all details are correct.
4. Input the facility's phone number to aid in communication.
5. Fill in the name and title of the facility representative who is submitting the form.
6. Indicate the date of submission, ensuring that it reflects the correct date.
7. Select the type of curriculum that the staff person completed by checking the appropriate box: Nursing assistant, Geriatric assistant, or Home health aide.
8. State who provided the curriculum by filling in the relevant section with the name and address of the entity.
9. Document the trainer’s name, title, sponsoring entity, and their qualifications in the provided space.
10. Specify the number of clock hours involved in the training curriculum and indicate whether it included classroom and clinical instruction by checking 'Yes' or 'No'.
11. Provide the date(s) when the staff person obtained their training.
12. Check all included components of the curriculum, such as core curriculum topics, basic skills, and rights for residents, as necessary.
13. Attach an outline of the course/curriculum to ensure completeness. The instruction should total approximately 40 hours.
14. Once all information is complete, save changes, and prepare to download, print, or share the form as needed.

Complete your documents online today for a streamlined filing experience.