COLORADO BOARD OF NURSING by ay5aByO

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									                              Nurse Aide Training Change of Program Coordinator Form
                Please download, type, sign, and return the completed original to the Board by U.S. Mail to:
                                             Nurse Aide Compliance Manager
                                                  State Board of Nursing
                                                 1560 Broadway, Ste 1350
                                                     Denver, CO 80202
          This form must be reviewed and signed by the Program Coordinator on the last page of the form.

1) Official Name of Training Program:                     Program Code:
2) Name of Program Coordinator:
3) Contact Information:                Address:
                                       Phone:
                                       Email:
4) Name of New Coordinator:                   Colorado RN License #:
5) Phone #: (         )       -       E-Mail Address:
6) Start Date:            /       /
7) Will the Program Coordinator also serve as a Primary Instructor?                        Yes      No
8) Document required nursing experience. (List 24 months clinical nursing experience. One (1) year of Long Term Care
  experience is required. Supply most recent germane experience first. “See Résumé” or “See Curriculum Vitae” will not be accepted
  in lieu of completing this form. )
 Employer                                  Job Title                                                 Dates of Employment
                                           (List Primary Duties)                                     (e.g., 02/06)
  Employer:                                Job Duties:                                                From:           /
  City:                                                                                               To:             /
  State
  Employer:                                Job Duties:                                                From:           /
  City:                                                                                               To:             /
  State
  Employer:                                Job Duties:                                                From:           /
  City:                                                                                               To:             /
  State
  Employer:                                Job Duties:                                                From:           /
  City:                                                                                               To:             /
  State
  Employer:                                Job Duties:                                                From:           /
  City:                                                                                               To:             /
  State

9) Document one or more of the following and attach any certificates or supporting documentation:
 Education Experience Type             Location of Education Experience          Dates of Experience
                                                                                                     (e.g., 10/08)
 Documented Experience Teaching Adults:              Employer:                                        From:           /
    Yes        No                                    City:                                            To:             /
                                                     State
 Training in Teaching Adults: (e.g., Train the       Training:                                        From:           /
 Trainer)    Yes       No                            City:                                            To:             /
                                                     State
 One Year Experience Managing Nurse Aides:           Employer:                                        From:           /
    Yes        No                                    City:                                            To:             /
                                                     State



Reminder: The Board requires notification of significant changes prior to their implementation.
10) I, ____________________________________, acknowledge and accept the responsibility for conducting
           the nurse aide training program in a manner that complies with Chapter XI Rules and Regulations
           for Approval of Nurse Aide Training Programs and all other applicable federal and state regulations.



______________________________________
                (Signature Here)
                                                                                            Program Coordinator Qualified: Y/N
                                                                                            If No, elaborate:______________
                                                                                                       Board Use Only
Reviewed and Approved by:



 _____________________________________________________
  Program Coordinator




Reminder: The Board requires notification of significant changes prior to their implementation.

								
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