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KCTCS Transformation

Secondary Partners - Annual Nurse Aide Report 2018-2019

Nurse Aide Reporting Form

The following information needs to submitted by May 15, 2019 or before you leave for the summer. Failure to submit a report in a timely manner will result in your program being placed on a Plan of Correction. Please contact Vicki Weaver at vicki.weaver@education.ky.gov if you experience any difficulty or have any questions concerning this report.

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1. Please enter your School Contact Information
This question requires a valid email address.
2. Please enter your training provider approval number(s):
4. RN Primary Instructor Information
5. Nurse Aide Instructor InformationState and Federal regulation requires that nurse aide instructruction be performed by or under the general supervision of a registered nurse who has a minimum of two (2) years experience, at least one (1) of which shall be in LTC. This information is required to be submitted in the annual report. In compliance with these requirements, please provide the following information.
Instructor Name KBN License # One Year LTC Experience
Yes No
NA Instructor #1
NA Instructor #2
NA Instructor #3
NA Instructor #4
6. Clinical Site InformationPlease list out all clinical sites used in this reporting period. Each program is required to verify the status of a facility prior to each class entering the facility for a clinical experience.
Clinical Site Name Civil Money Penalty or Extended Survey Date Clinical MOA Signed
Yes No
Clinical Site #1
Clinical Site #2
Clinical Site #3
Clinical Site #4
Clinical Site #5
Clinical Site #6
7. Please enter the following numbers for your secondary training program:
This question requires a valid percent format.
8. Please enter the following numbers for your adult training program if applicable, otherwise skip this section.
This question requires a valid percent format.
Please feel free to enter any comments, suggestions, feedback, or additional evaluator/instructor/clinical site information in the space below.
Please electronically sign acknowledging accurate completion of this form. *This question is required.
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