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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