Failure to supply adequate information to meet state and federal instructor requirements will result in non-approval of application. Proof of 24-hour BRN approved DSD class or transcript of college courses related to education programs in nursing. Copy of active nursing license. Name Mailing Address Number and Street or P. O. Box Number City Zip Code Administrator / Program Director Signature and Title Printed Name Date Director of Nursing Signature FOR OFFICE USE ONLY Approved CDPH 279 06/14 By Program Consultant This form is available on our website at www. O. Box 997416 Sacramento CA 95899-7416 PHONE 916 327-2445 FAX 916 324-0901 State of California- Health and Human Services Agency DIRECTOR OF STAFF DEVELOPMENT DSD / INSTRUCTOR APPLICATION TYPE OR PRINT LEGIBLY Facility/School/Agency Telephone Number Provider Identification Training Number S or F Number County Type of Training to be Offered Orientation and In-Service Training Programs Only Nurse Assistant Training Program NATP Only....
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How to fill out the CA CDPH 279 online
The CA CDPH 279 form is essential for individuals seeking approval as instructors or directors of staff development in California's training programs. This guide provides a clear, step-by-step approach to help users accurately complete the form online.
Follow the steps to effectively fill out the form
- Press the ‘Get Form’ button to access the document and open it in your preferred online editor.
- Fill in the facility or school telephone number along with the provider identification training number, which could be an 'F' or 'S' number.
- Provide the full name and mailing address of the facility or school.
- Select the types of training you plan to offer by checking the appropriate boxes, such as orientation and in-service training programs or nurse assistant training programs.
- If applicable, enter your nursing license number as a registered nurse (RN) or licensed vocational nurse (LVN).
- Complete your personal details, including your full name, mailing address, telephone number, and email address.
- If you have previously been approved, enter your instructor or DSD number in the designated section.
- Sign and date the application, indicating your employment hours per week and your employment date as an instructor or DSD.
- Provide information on the licensed bed capacity of your facility (if applicable).
- If you are not previously approved as an instructor or DSD, upload the required documentation, including a resume, proof of nursing experience, and course completion certificates.
- Collect signatures and contact information from the administrator/owner and the director of nursing/program director to confirm the applicant meets the qualifications.
- Finally, review the completed form before saving your changes, downloading, printing, or sharing the completed document as needed.
Begin filling out your CA CDPH 279 form online today to ensure a smooth application process.
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