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Get CA CDPH 279 2019-2024

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 Orientation In-Service and NATP Applicant s Name Registered Nurse RN Licensed Vocational Nurse LVN California Nursing License Number Expiration Date Facility Licensed Bed Capacity if applicable Date Submitted to CDPH Signature of Applicant Hours Employed per week Date Employed as DSD / Instructor per month Please Submit Resume showing work experience. California Department of Public Health CDPH Licensing and Certification Program L C Aide and Technician Certification Section ATCS MS 3301 P. Include month/year to month/year of work experience name and address of employer contact telephone number for HR or administration to validate the work experience and the name of supervisor. 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. Include month/year to month/year of work experience name and address of employer contact telephone number for HR or administration to validate the work experience and the name of supervisor. 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.

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