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Director of Staff Development (DSD) / Instructor Application

This document is an application for a Director of Staff Development (DSD) or instructor position. It requests information such as the applicant's name, nursing license number and expiration date. It also requests information about the facility or agency where the applicant will work, including the name, address, number of licensed beds, and signatures of the administrator/program director and director of nursing. The application instructs applicants to submit documentation of relevant work experience, proof of approved DSD training, and a copy of their active nursing license. It will be reviewed and either approved or not approved by a CDPH program consultant.

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AMEU URGENCIAS
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82 views1 page

Director of Staff Development (DSD) / Instructor Application

This document is an application for a Director of Staff Development (DSD) or instructor position. It requests information such as the applicant's name, nursing license number and expiration date. It also requests information about the facility or agency where the applicant will work, including the name, address, number of licensed beds, and signatures of the administrator/program director and director of nursing. The application instructs applicants to submit documentation of relevant work experience, proof of approved DSD training, and a copy of their active nursing license. It will be reviewed and either approved or not approved by a CDPH program consultant.

Uploaded by

AMEU URGENCIAS
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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State of California- Health and Human Services Agency California Department of Public Health (CDPH)

Licensing and Certification Program (L&C)


Aide and Technician Certification Section (ATCS)
MS 3301, P.O. Box 997416
Sacramento, CA 95899-7416
PHONE: (916) 327-2445 FAX: (916) 324-0901

DIRECTOR OF STAFF DEVELOPMENT (DSD) / INSTRUCTOR


APPLICATION
TYPE OR PRINT LEGIBLY
Facility/School/Agency Telephone Number County Provider Identification Training Number (“S” or “F” Number)

Facility / School / Agency Name and Address:

Type of Training to be Offered:


Orientation and In-Service Training Programs Only
Nurse Assistant Training Program (NATP) Only
Orientation, In-Service, and NATP

Applicant’s Name Registered Nurse (RN) California Nursing License Number Expiration Date
Licensed Vocational Nurse (LVN)

Signature of Applicant

Hours Employed Date Employed as DSD / Instructor Facility Licensed Bed Capacity Date Submitted to CDPH
(if applicable)
________ per week _________ per month

Please Submit:
1) Resume showing work experience. Include month/year to month/year of work experience, name and address of employer, contact
telephone number for HR or administration to validate the work experience, and the name of supervisor. Failure to supply adequate
information to meet state and federal instructor requirements will result in non-approval of application.
2) Proof of 24-hour BRN approved DSD class or transcript of college courses related to education programs in nursing.
3) Copy of active nursing license.

Facility / School / Agency or Employer Information:


Name Telephone Number

Mailing Address (Number and Street or P.O. Box Number) City County Zip Code

Administrator / Program Director Signature and Title Printed Name Date

Director of Nursing Signature Printed Name Date

FOR OFFICE USE ONLY


Approved Date By: Program Consultant

CDPH 279 (06/14) This form is available on our website at: www.cdph.ca.gov Page 1 of 1

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