Home / cna inservice education / Form 3 Nurse Aide Instructor Verification - New York State …
Form 3 Nurse Aide Instructor Verification - New York State … - cna inservice education
FORM 3: Nurse Aide Instructor VerificationSubmit this form with the application cover sheet (Form 1). Attach a separate form for each program code number/site. School District or BOCES: FORMTEXT ?????Program Code Number: (Ex. 33x-xxxx) FORMTEXT ?????RN Nurse Instructor Name: FORMTEXT ?????Address: FORMTEXT ?????Phone: FORMTEXT ?????E-mail address: FORMTEXT ?????School/Site Name: FORMTEXT ?????Address: FORMTEXT ?????Phone: FORMTEXT ?????Required Documentation Yes No Professional Credential: copy of current New York State Professional Nurse Registration (attach) Professional Work Experience: verification of two years-experience in nursing home caring for the elderly and/or chronically ill (attach) Teaching Qualifications (at least one of the following - attach): Certification to teach nurse aide or practical nursing, or Licensure as a trade school teacher of nurse aides, or Three years of experience teaching nursing or nursing related programs to adults in an academic setting approved by the NYS Commissioner of Education, or Three years of experience teaching nurse aides in a residential health care facility, or Completion of a professionally recognized course in teaching adult learners. *Proof of teacher certification is required for secondary programs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Attestation SignatureI certify that the above information is correct and attest to program compliance with regulatory requirements:RN Nurse Aide Instructor Signature: Date: FORMTEXT ?????RN Program Coordinator Signature: Date: FORMTEXT ?????School Administrator Signature: Date: FORMTEXT ?????Mailing InstructionsNew York State Education DepartmentSecondary and Adult NATP programs inOffice of Career and Technical Educationpublic secondary and BOCES agencies89 Washington Avenue, Room 315 EBAlbany, New York 12234
What are the mandatory in-service hours for CNA? The CNA is required to have 1.0 hour of in-service each calendar month or a total of 12 hours for a full calendar year. Therefore, if certified in June, the CNA would be required to have 6 hours by December 31st.
