Nursing Assistant Program

Long-term Care Nursing Assistant Program
Education Forms

Criteria

Reference document to assist in applying for initial and on-going program approval of a NATCEP

Checklist for Submitting for a NATCEP

Reference document to be used in application for initial approval of a NATCEP

Application for Approval of Education Program

This form must be completed and submitted when:

Applying for approval of an initial NATCEP
Applying for approval of a change to an on-going NATCEP
- Change of location for class/lab or clinical setting
- Change in class/lab or clinical hours

Faculty Data

This form must be completed and submitted for each applicant upon:

Applying for initial approval of Program Director, Coordinator, Class/Lab Instructor and/or Clinical Instructor
NOTE: Attach a detailed resume’ and copy of Educate the Educator or Vocational Certificate/Permit to each form
Termination of a previously approved Program Director, Coordinator, Class/Lab Instructor and/or Clinical Instructor
NOTE: Failure to notify this office of personnel changes could result in loss of program approval

Resource Instructor Data

This form must be completed and submitted for each applicant when:

Applying for initial approval of a Resource Instructor having a minimum of one year current experience in their area of expertise
NOTE: At no time is a resource instructor an acceptable substitute for the class/lab or clinical instructor
To be completed and submitted upon termination of a previously approved Resource Instructor

Description of Instructional Materials

This form must be completed and submitted when:

Applying for initial approval of a NATCEP
Applying for changes to instructional materials for an on-going NATCEP

Description of Instructional Materials – Larger Course

This form must be completed and submitted when NATCEP has additional components other than long-term care nursing assistant training, such as Home Health Aide or Health Occupations

Skills Performance Record

This lists the minimum tasks/skills required to be taught and learned in the NATCEP. Space is provided to note observation and demonstration. The instructor must record return demonstration, record date of performance of the skill in the clinical setting, note satisfactory or unsatisfactory performances and the date when the performances is determined to be appropriate for no further direct supervision, and the name of the instructor(s). This record is to be kept current as the student progresses.

NOTE: A copy of this record is to be kept in the personnel file and the original given to the student upon graduation.

Description for Performance of Skills

This is a step-by-step reference to skills performance

Minimum Cirriculum Requirements Checklist

Reference document to assist in assuring that all minimum curriculum requirements are listed on the calendar and met by the NATCEP Program.

Calendar Checklist

This form can be used for Program Coordinator and/or Instructor reference when preparing the NATCEP Program Calendar

Calendar Checklist - Secondary Education Program (Vo-Tech)

This form can be used for Program Coordinator and/or Instructor reference when preparing the NATCEP Program Calendar

Calendar Checklist – Adult Education Program (Vo-Tech)

This form can be used for Program Coordinator and/or Instructor reference when preparing the NATCEP Program Calendar

NATCEP Questionnaire

This form must be completed by the Nursing Home Administrator and/or DON of the certified nursing home of which the NATCEP will hold the clinical portion of class and submitted when:

Applying for initial approval of a NATCEP
Applying for approval of a calendar and class to begin for an on-going NATCEP

Class Roster Form

This form must be completed legibly in its entirety and submitted at least one week prior to the beginning of the NATCEP start date. Additions and deletions may be submitted up to the end of the first day of class.

NOTE: ANY ADDITIONS SUBMITTED AFTER THE END OF THE FIRST DAY OF CLASS WILL NOT BE ACCEPTABLE AND THE STUDENT WILL NOT BE ELIGIBLE TO TEST AT THE END OF THE NATCEP

Completion of Training Form

This form must be completed legibly in its entirety and submitted within 30days following completion of the program and prior to application for testing are sent to the contracted testing service. A copy of this form must be kept on file by the NATCEP provider for each class completed

NOTE: This form will not be accepted if a class roster and/or class calendar was not submitted and received prior to the class start date and/or class calendar not being approved prior to the NATCEP beginning.

Quality Assurance Survey Form

You may complete and submit this form after an investigation and/or NATCEP survey has been conducted at your facility