Ala. Admin. Code ch. 620-X-A | Alabama Administrative Code Chapter 620-X-A — Appendix A Forms

620 Alabama Board of Examiners of Nursing Home Administrators

Ala. Admin. Code r. 620-X-A-.01 Complaint Form

Appendix A – FORM 1

Ala. Admin. Code r. 620-X-A-.02 Oral Examination Form (Repealed 2/20/01)

FORM-2 -- Oral Examination Form

(Repealed 2/20/01)

History

Authority: Code of Ala. 1975, §34-20-14.
Repealed: Filed January 16, 2001; effective February 20, 2001.

Ala. Admin. Code r. 620-X-A-.03 Application For License As A Nursing Home Administrator

Appendix A – Form 3

State of Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road

Montgomery, Alabama 36106

(334) 271-2342

Application for License as a Nursing Home Administrator

Please print clearly or type all answers. If there is no sufficient space, use additional sheets and number accordingly. Your completed employment verification, copy of facility institutional license, photograph, organizational chart, three character references, a copy of your college degree, copy of current driver’s license, and the required fee (see fee schedule), made payable to the AL BOE of Nursing Home Administrators, must be submitted with this application. Your application will not be considered complete and therefore will not be reviewed unless all of the above have been received.

I hereby make application for a Regular License as a Nursing Home Administrator in the State of Alabama.

Date:

Name:

(Last) (First) (Middle) (Maiden)

Home Address:

(Street) (City) (State) (Zip)

Business Address:

(Street) (City) (State) (Zip)

Telephone Number: (Cell) (Business)
Date of Birth: Place of Birth:

(Month) (Day) (Year)

Are you a citizen of the United States? Yes ? No ? Country
Social Security Number:
Education: (a) Please circle the highest grade completed: 6 7 8 9 10 11 12

(b) Did you graduate? Yes ? No ? Date of Graduation

Address:

(Street) (City) (State) (Zip)

(d) Name of College or University

Address

(e) Degree

(f) Major undergraduate subjects:

(g) Major graduate university subjects:

(h) Other educational training: Name

Address:

(Street) (City) (State) (Zip)

Dates attended: From To

Certificate Received: Yes ? No ?

Subjects:

Employment history for the past 15 years, include military experience, if any. Please list most recent experience first.

Employers Name

Address:

(Street) (City) (State) (Zip)

Employed: From To

List your title and a detailed description of duties performed, include number and type of employees supervised.

Employers Name

Address:

(Street) (City) (State) (Zip)

Employed: From To

List your title and a detailed description of duties performed, include number and type of employees supervised.

Employers Name

Address:

(Street) (City) (State) (Zip)

Employed: From To

List your title and a detailed description of duties performed, include number and type of employees supervised.

Employers Name

Address:

(Street) (City) (State) (Zip)

Employed: From To

List your title and a detailed description of duties performed, include number and type of employees supervised.

Employers Name

Address:

(Street) (City) (State) (Zip)

Employed: From To

List your title and a detailed description of duties performed, include number and type of employees supervised.

Membership in Professional Societies and Nursing Home Associations:

Name Date of Membership Offices Held Active or Inactive

Professional Certificates and/or licenses held. (Include such items as fellowships in American College of Hospital Administrators and American College of Health Care Administrators, MD, RN, LPN, CPA, etc. Do not include academic degrees. Give complete information for each certificate or license you hold or have ever held).

Type of certificate Name of State or Year of Original Year of Latest Current or Latest

or license other authority issue issue registration number

Attach a recent (within 3 months) finished unmounted photograph. Type or print you name of the back of the photograph.
Have you ever been convicted of a felony? Yes ? No ?
Have you ever been treated for illness caused by excessive use of alcohol or narcotics? Yes ? No ?
In what type of nursing facility are you currently employed?
Attach a copy of the current license issued to the facility you are now affiliated with.
Have you applied for licensure by examination in any state or states for license as a nursing home administrator? Yes ? No ? State(s)
Have you ever had a certificate or other professional license revoked or suspended?

Yes ? No ? If yes, attach an explanation, relevant documents and a description of the current status.

Are you currently registered as a nursing home administrator in any other state?

Yes ? No ? If yes, please have the applicable State Licensure Board complete the enclosed reciprocity questionnaire. A questionnaire must be filled out for each state in which you hold or have held a nursing home administrators license.

Applicant must furnish references from three (3) individuals who are in a position to provide information in regard to your good moral character. These should be mailed by the individuals directly to the Board of Examiners. Please list below the names and addresses of who the three references will be from:

(1) Name Business or Occupation

Address:

(Street) (City) (State) (Zip)

(2) Name Business or Occupation

Address:

(Street) (City) (State) (Zip)

(3) Name Business or Occupation

Address:

(Street) (City) (State) (Zip)

Affidavit of Applicant

, on oath, do promise and swear that, if my application is accepted, and I should be granted a license to practice as a Nursing Home Administrator in the State of Alabama, I will obey the laws of the State, the Rules and applications of the Alabama Board of Examiners of Nursing Home Administrators, and maintain the honor and dignity of the profession.

It is understood and agreed that, if I should fail to keep the above agreement or if I have made any false statements in this application, my license may be suspended or revoked by the Board at any time.

I further state that all the statements are made by me in this application are true and correct.

Signature of Applicant

Sworn to and subscribed before me this

day of , .

My Commission Expires

Notary Public

STATE OF )

COUNTY OF )

EMPLOYMENT VERIFICATION AFFIDAVIT

Before me, the undersigned Notary Public in and for said County, in said State,

personally appeared , who is known to me and

who, being duly sworn on oath deposes and says:

The affiant is of

(Title - owner, co-owner, officer, director, etc.)

and is personally acquainted with

(Nursing facility)

, who is an applicant for a license as a

nursing home administrator under the rules governing nursing home administrators

licensed under the laws of the State of Alabama, and that applicant has been

employed by the nursing facility from to .

(Date) (Date)

That applicant has good moral character and reputation where he/she resides,

and enjoys the confidence and respect of the general public. His/Her duties

are summarized as follows with dates indicated where appropriate to reflect

major duty changes or changes in responsibility:

Affiants Signature

Sworn to and subscribed before me

this day of , .

Notary Public My Commission Expires

County of

State of

History

Author: Linda U. Jordan, Chairman
Authority: Code of Ala. 1975, §34-20-5.
December 31, 1992. Filed: Amended: August 31, 1993. Amended: Filed January 16, 2001; effective February 20, 2001. Amended: Filed June 15, 2016; effective July 30, 2016.

Ala. Admin. Code r. 620-X-A-.04 Application For Renewal Of NHA Nursing Home Administrator

Appendix A – Form 4

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

Application for Renewal of NHA License

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NHA License # ______________ E-mail address _________________ Date __________

Last Four Digits Social Security # ___________

In accordance with Act No. 986, Regular Session, 1969, I hereby make application for renewal of my license as a nursing home administrator with the Alabama Board of Examiners of Nursing Home Administrators.

NAME:

(Title) (Last) (First) (Middle)

ADDRESS: (Street) (City)

(State) (Zip Code)

Please give current home address

NAME OF FACILITY OR BUSINESS:

TELEPHONE: (Cell) (Business)

During the last year, have you been convicted of a felony or misdemeanor (other than minor traffic violation); entered a plea of guilty; entered a plea under a first offender provision; been a defendant in a malpractice claim or had a professional license or membership sanctioned either publicly or privately?

No O Yes O If yes, attach copy of relevant documents.

In addition to this license, I hold the following other professional licenses:

License: ; ;

(Title) (Number) (State)

; ;

(Title) (Number) (State)

Not Applicable O

Affidavit of Applicant

I hereby certify that the (total hours) continuing education hours listed on this application are true and correct to the best of my knowledge and belief.

History

Author: Lana Davis, Chairman
Authority: Code of Ala. 1975, §34-20-13.
Amended: Filed January 16, 2001; effective February 20, 2001. Amended: Filed August 8, 2011; effective September 12, 2011. Amended: Filed March 13, 2012; effective April 17, 2012. Amended: Filed June 15, 2016; effective July 30, 2016. Amended: Published January 31, 2022; effective March 17, 2022.

Ala. Admin. Code r. 620-X-A-.05 Reciprocity Questionnaire

Appendix A – Form 5

State of Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road

Montgomery, Alabama 36106

(334) 271-2342

Reciprocity Questionnaire

TO THE APPLICANT:

If you are applying for the state examination for Nursing Home Administrators on the basis of your licensure in another state, please have the following certification completed by the Executive Officer of the Board of Examiners of Nursing Home Administrators of the state(s) in which you hold or have held a license as a Nursing Home Administrator.

Name

Address

TO BE COMPLETED BY STATE BOARD OFFICIAL:

Applicant's name (as shown on your records)

Address

Social Security Number

Telephone Number Home - Work -

License Number Date Issued _______________________

Expiration Date ______________________

Education: High School ? College ? Graduate ? Post Graduate ?

Please mark the highest level

State of Original License

Status of License: Active ? Inactive ? Expired ?

Exam Score: Type: NAB ? PES ? Other ?

Raw Score Scale Score ______________________

Date of Exam

Did applicant complete an AIT/Practicum Program in your State? Yes ? No ?

If yes, length of AIT/Practicum

Is applicant in good standing with your board at this time? Yes ? No ?

If no, please explain

Has applicant ever been disciplined by your Board? Yes ? No ?

If yes, please explain

Is the applicant currently being investigated for any possible criminal action

or future board disciplinary action? Yes ? No ?

If yes, please explain

I certify that the information provided is true and correct, according to the records of the board.

(date) (signature of executive officer)

(State Board)

(address)

(city) (state) (zip)

(area code) (telephone)

PLEASE RETURN TO:

Executive Secretary

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road

Montgomery, Alabama 36106

History

Author: Jacob L. Cureton, Jr.
Authority: Code of Ala. 1975, §34-20-12.
Amended: Filed January 16, 2001; effective February 20, 2001.

Ala. Admin. Code r. 620-X-A-.06 Course Approval Form

Appendix A - Form 6

State of Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road

Montgomery, Alabama 36106

(334) 271-2342

Request for Course Approval

PLEASE MAKE SURE YOU ATTACH A BROCHURE FOR REVIEW

Submitted By:
Address:
Course Title:
Course Date & Location:
Course Objective and Content: (A short paragraph describing the purpose of the course.)
Number of Hours requested

(Only count actual classroom hours. No credit can be given to the time spent in registration, coffee breaks, luncheons, dinners, or other nonformalized educational activities such as social hours.)

Sponsors of the Course: Name

Address

Phone

Principle Faculty/Lectures/Speakers:

ANY COURSE NOT RECEIVED IN THE BOE OFFICE AT LEAST 30 DAYS PRIOR TO THE DATE OF THE COURSE WILL NOT BE REVIEWED

History

Author: Jacob L. Cureton, Jr.
Authority: Code of Ala. 1975, §34-20-13.
Amended: January 16, 2001; effective February 20, 2001.

Ala. Admin. Code r. 620-X-A-.07 Application For Administrator-In-Training

Appendix A – Form 7

State of Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road

Montgomery, Alabama 36106

(334) 271-2342

Application for Administrator-In-Training

Please print clearly or type all answers. If there is no sufficient space, use additional sheets and number accordingly. A copy of your AIT program, A copy of your Preceptor's application and certificate, A copy of the Application for facility training site, A copy of your college degree, and the required fee (see fee schedule), made payable to the AL BOE of Nursing Home Administrators, must be submitted with this application. Your application will not be considered complete and therefore will not be reviewed unless all of the above have been received.

I hereby make application for Administrator-in-Training in the State of Alabama.

E-Mail Address Date:

Name:

(Last) (First) (Middle) (Maiden)

Home Address:

(Street) (City) (State) (Zip)

Business Address:

(Street) (City) (State) (Zip)

Telephone Number: (Home) (Business)
Date of Birth: Place of Birth:

(Month) (Day) (Year)

Are you a citizen of the United States? Yes ? No ? Country
Social Security Number:
Education: (a) Please circle the highest grade completed: 6 7 8 9 10 11 12

(b) Did you graduate? Yes ? No ? Date of Graduation

Address:

(Street) (City) (State) (Zip)

(d) Name of College or University

Address

(e) Degree

(f) Major undergraduate subjects:

(g) Major graduate university subjects:

(h) Other educational training: Name

Address:

(Street) (City) (State) (Zip)

Dates attended: From To

Certificate Received: Yes ? No ?

Subjects:

Professional Certificates and/or licenses held. (Include such items as fellowships in American College of Hospital Administrators and American College of Health Care Administrators, MD, RN, LPN, CPA, etc. Do not include academic degrees. Give complete information for each certificate or license you hold or have ever held).

Type of certificate Name of State or Year of Original Year of Latest Current or Latest

or license other authority issue issue registration number

Have you ever been convicted of a felony? Yes ? No ?
Have you ever been treated for illness caused by excessive use of alcohol or narcotics? Yes ? No ?
Have you applied for licensure by examination in any state or states for license as a nursing home administrator? Yes ? No ? State(s)
Have you ever had a certificate or other professional license revoked or suspended?

Yes ? No ? If yes, attach an explanation, relevant documents and a description of the current status.

Are you currently registered as a nursing home administrator in any other state?

Yes ? No ?

Affidavit of Applicant

, on oath, do promise and swear that, if my application is accepted, I will obey the laws of the State, the Rules and applications of the Alabama Board of Examiners of Nursing Home Administrators, and maintain the honor and dignity of the profession.

It is understood and agreed that, if I should fail to keep the above agreement or if I have made any false statements in this application, I may not be able to obtain an Alabama Nursing Home Administrators License.

I further state that all the statements are made by me in this application are true and correct.

Signature of Applicant

Sworn to and subscribed before me this

day of , .

My Commission Expires

Notary Public

History

Author: Lana Davis
Authority: Code of Ala. 1975, §34-20-9.
Amended: Filed January 16, 2001; effective February 20, 2001. Amended: Published January 31, 2022; effective March 17, 2022.

Ala. Admin. Code r. 620-X-A-.08 Application For Preceptor

Appendix A – Form 8

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

Application for Preceptor

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NHA License # Date of Issuance

NAME:

(Title) (Last) (First) (Middle)

DATE OF BIRTH:

(Month) (Day) (Year)

ADDRESS: (Street) (City)

(State) (Zip Code)

Please give current home address

TELEPHONE: (Home) (Business)

Have you had any disciplinary action taken against any professional license you hold? No ? Yes ?

No ? Yes ? If yes, attach copy of relevant documents.

In addition to this license, I hold the following other nursing home administrator licenses: Not Applicable ?

License: ; ; ;

(Title) (Number) (State)

; ; ;

(Title) (Number) (State)

Please list the names, addresses, and dates of the facilities in which you have been in direct management control over the last three years. Please list current facilities first

Please list your experience that would qualify you to supervise the training of an AIT.

Education: Please submit a copy of all degrees and certificates you have received.

(a) Please circle the highest grade completed: 6 7 8 9 10 11 12

(b) Did you graduate? Yes ? No ? Date of Graduation

Address:

(Street) (City) (State) (Zip)

(d) Name of College or University

Address

(e) Degree

(f) Major undergraduate subjects:

(g) Major graduate university subjects:

(h) Other educational training: Name

Address:

(Street) (City) (State) (Zip)

Dates attended: From To

Certificate Received: Yes ? No ?

Subjects:

Please submit a copy of your current resume and a copy of your Preceptor Training Certificate.

I hereby certify that the information listed on this application are true and correct to the best of my knowledge and belief.

In witness whereof, I set my hand and seal this day of , .

(Signature of Applicant)

Sworn to and Subscribed before me this day of , .

(Notary Public)

My Commission Expires County of State of

History

Author: Jacob L. Cureton, Jr.
Authority: Code of Ala. 1975, §34-20-9.
Amended: January 16, 2001; effective February 20, 2001.

Ala. Admin. Code r. 620-X-A-.09 Application For Facility Training Site

Appendix A – Form 9

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

Application for Facility Training Site

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NAME OF FACILITY:

ADDRESS: (Street) (City)

(State) (Zip Code)

TELEPHONE: (Fax)

NUMBER OF LICENSED BEDS: COUNTY:

OWNER:

Please provide the following information on the facility key staff and department heads:

NAME POSITION IN FACILITY DATE HIRED WORK HOURS TYPE OF LICENSE HELD LICENSE #

PLEASE ATTACH THE LATEST COPY OF YOUR SURVEY REPORT (HCFA 2567) WHICH INCLUDES YOUR PLAN OF CORRECTION AND A COPY OF YOUR FACILITY LICENSE ISSUED FROM THE DIVISION OF LICENSURE AND CERTIFICATION.

History

Author: Jacob L. Cureton, Jr.
Authority: Code of Ala. 1975, §34-20-9.
Amended: January 16, 2001; effective February 20, 2001.

Ala. Admin. Code r. 620-X-A-.10 AIT Program Outline - 1000 Hour Program

Appendix A – Form 10

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

AIT PROGRAM OUTLINE - 1000 HOUR

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NAME OF AIT: Date

(Title) (Last) (First) (Middle)

NAME OF FACILITY WHERE TRAINING IS TAKING PLACE:

ADDRESS:

TELEPHONE: FAX:

Proposed AIT Beginning Date: Proposed date of Completion:

CARE, SUPPORTS, AND SERVICES: (A minimum of 440 hours) TOTAL HOURS

Topics in this area should include nursing services, social services, food service, medical services, therapeutic services, recreational and activity programs, medical records, pharmaceutical program and rehabilitation services.

NURSING SOCIAL SERVICES

DIETARY RECREATION/VOLUNTEER

MEDICAL RECORDS REHABILITATION SERVICES

MEDICAL/ALLIED HEALTH PHARMACEUTICAL PROGRAM

OPERATIONS: (A minimum of 270 hours) TOTAL HOURS

Topics in this area should include recruitment, interviewing, employee selection, training, personnel policies, employee health and safety program, employee retention, accounting, budgeting, financial planning and asset managing, auditing, organizational structures, leadership principles, mission, vision and value statements, strategic planning, government relations and advocacy, and public relations.

ADMINISTRATION BUSINESS

ENVIRONMENT AND QUALITY: (A minimum of 260 hours) TOTAL HOURS

Topics in this area should include safety procedures, fire, disaster and emergency programs, building and environmental management, compliance with laws and regulations and governing entities, risk management, communication, survey, certification, enforcement, quality improvement models and management information systems.

HOUSEKEEPING/LAUNDRY MAINTENANCE

OTHER (30 hours): TOTAL HOURS

TOTAL NUMBER OF HOURS IN AIT TRAINING PROGRAM

TO BE COMPLETED BY THE SUPERVISING LICENSED NURSING HOME ADMINISTRATOR:

I certify that the AIT whose signature appears below has agreed to complete this AIT program of hours under my personal supervision.

(Signature of Preceptor)

AL NHA License #

(Signature of AIT)

History

Author: Lana Davis, Chairman
Authority: Code of Ala. 1975, §34-20-9.
Amended: January 16, 2001; effective February 20, 2001. Amended: Filed September 11, 2003; effective October 16, 2003. Amended: Filed July 21, 2017; effective September 4, 2017. Amended: Published January 31, 2022; effective March 17, 2022.

Ala. Admin. Code r. 620-X-A-.11 AIT Program Outlined - 2000 Hour Program

Appendix A – Form 11

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

AIT PROGRAM OUTLINE - 2000 HOUR

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NAME OF AIT: Date

(Title) (Last) (First) (Middle)

NAME OF FACILITY WHERE TRAINING IS TAKING PLACE:

ADDRESS:

TELEPHONE: FAX:

Proposed AIT Beginning Date: Proposed date of Completion:

CARE, SUPPORTS, AND SERVICES: (A minimum of 880 hours) TOTAL HOURS

NURSING SOCIAL SERVICES

DIETARY RECREATION/VOLUNTEER

MEDICAL RECORDS REHABILITATION SERVICES

MEDICAL/ALLIED HEALTH PHARMACEUTICAL PROGRAM

OPERATIONS: (A minimum of 540 hours) TOTAL HOURS

ADMINISTRATION BUSINESS

ENVIRONMENT AND QUALITY: (A minimum of 520 hours) TOTAL HOURS

HOUSEKEEPING/LAUNDRY MAINTENANCE

OTHER (60 hours): TOTAL HOURS

TOTAL NUMBER OF HOURS IN AIT TRAINING PROGRAM

TO BE COMPLETED BY THE SUPERVISING LICENSED NURSING HOME ADMINISTRATOR:

I certify that the AIT whose signature appears below has agreed to complete this AIT program of hours under my personal supervision.

(Signature of Preceptor)

AL NHA License #

(Signature of AIT)

History

Author: Lana Davis, Chairman
Authority: Code of Ala. 1975, §34-20-9.
Amended: January 16, 2001; effective February 20, 2001. Amended: Filed September 11, 2003; effective October 16, 2003. Amended: Filed July 21, 2017; effective September 4, 2017. Amended: Published January 31, 2022; effective March 17, 2022.

Ala. Admin. Code r. 620-X-A-.12 Certification Of Program Completion - 1000 Hour Program

Appendix A – Form 12

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

CERTIFICATION OF PROGRAM COMPLETION - 1000 HOUR PROGRAM

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NAME: Date

(Title) (Last) (First) (Middle)

NAME OF FACILITY WHERE TRAINING IS TAKING PLACE:

ADDRESS:

TELEPHONE: FAX:

DATE PROGRAM BEGAN: DATE PROGRAM COMPLETED:

CARE, SUPPORTS, AND SERVICES: (A minimum of 440 hours) TOTAL HOURS

OPERATIONS: (A minimum of 270 hours) TOTAL HOURS

ENVIRONMENT AND QUALITY: (A minimum of 260 hours) TOTAL HOURS

OTHER (30 hours): TOTAL HOURS

TOTAL NUMBER OF HOURS IN AIT TRAINING PROGRAM

TO BE COMPLETED BY THE SUPERVISING LICENSED NURSING HOME ADMINISTRATOR:

I certify that the AIT whose signature appears below has satisfactorily completed this AIT program of hours under my personal supervision.

Narrative evaluation of suitability for licensure as a nursing home administrator:

(Signature of Preceptor)

AL NHA License #

(Signature of AIT)

History

Author: Lana Davis, Chairman
Authority: Code of Ala. 1975, §34-20-9.
Amended: January 16, 2001; effective February 20, 2001. Amended: Filed September 11, 2003; effective October 16, 2003. Amended: Filed July 21, 2017; effective September 4, 2017. Amended: Published January 31, 2022; effective March 17, 2022.

Ala. Admin. Code r. 620-X-A-.13 Certification Of Program Completion - 2000 Hour Program

Appendix A – Form 13

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

CERTIFICATION OF PROGRAM COMPLETION - 2000 HOUR PROGRAM

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NAME: Date

(Title) (Last) (First) (Middle)

NAME OF FACILITY WHERE TRAINING IS TAKING PLACE:

ADDRESS:

TELEPHONE: FAX:

DATE PROGRAM BEGAN: DATE PROGRAM COMPLETED:

CARE, SUPPORTS, AND SERVICES: (A minimum of 880 hours) TOTAL HOURS

OPERATIONS: (A minimum of 540 hours) TOTAL HOURS

ENVIRONMENT AND QUALITY: (A minimum of 520 hours) TOTAL HOURS

OTHER (60 hours): TOTAL HOURS

TOTAL NUMBER OF HOURS IN AIT TRAINING PROGRAM

TO BE COMPLETED BY THE SUPERVISING LICENSED NURSING HOME ADMINISTRATOR:

I certify that the AIT whose signature appears below has satisfactorily completed this AIT program of hours under my personal supervision.

Narrative evaluation of suitability for licensure as a nursing home administrator:

(Signature of Preceptor)

AL NHA License #

(Signature of AIT)

History

Author: Lana Davis, Chairman
Authority: Code of Ala. 1975, §34-20-9.
Amended: January 16, 2001; effective February 20, 2001. Amended: Filed September 11, 2003; effective October 16, 2003. Amended: Filed July 21, 2017; effective September 4, 2017. Amended: Published January 31, 2022; effective March 17, 2022.

Ala. Admin. Code r. 620-X-A-.14 AIT Quarterly Report Form

Appendix A – Form 14

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

AIT QUARTERLY REPORT FORM

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

AIT reports are to be sent in every three months following the start of training. Prior to the end of each three month period, a report form will be sent to you for completion. The AIT report shall be used to list experience gained since the date your training started.

NAME: Date

(Title) (Last) (First) (Middle)

NAME OF FACILITY WHERE TRAINING IS TAKING PLACE:

THIS REPORT COVERS THE PERIOD FROM TO

DURING THIS PERIOD I RECEIVED HOURS OF AIT TRAINING AND I WORKED DAYS PER WEEK.

For Additional Comments: use reverse side of this form and/or additional pages.

List assignments and departments with time spent in each:
Summary of learning experiences:
Brief analysis of any problems observed, new experiences, insights gained:
Statement of any problems that arose during the training:
Visits outside the facility, educational conferences attended:

I hereby certify that the information listed on this report form are true and correct to the best of my knowledge and belief.

(Signature of AIT)

The training that I have listed was supervised by:

TO BE COMPLETED BY THE SUPERVISING LICENSED NURSING HOME ADMINISTRATOR:

I certify that the AIT under my supervision has had the training listed and that this AIT

received hours of training and worked days per week during this period.

(Signature of Preceptor)

History

Author: Jacob L. Cureton, Jr.
Authority: Code of Ala. 1975, §34-20-9.
Amended: January 16, 2001; effective February 20, 2001.

Ala. Admin. Code r. 620-X-A-.15 Application For Temporary Manager (Repealed 4/17/12)

Appendix A – Form 15

Application for Temporary Manager

(Repealed 4/17/12)

History

Author: Jacob L. Cureton, Jr.
Authority: Code of Ala. 1975, §34-20-9.
Amended: January 16, 2001; effective February 20, 2001. Repealed: Filed March 13, 2012; effective April 17, 2012.

Ala. Admin. Code r. 620-X-A-.16 Application For Preceptor Recertification

Appendix A – Form 16

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

Application for Preceptor Recertification

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NHA License # Date of Issuance

Preceptor License # Date of Issuance

NAME:

(Title) (Last) (First) (Middle)

DATE OF BIRTH:

(Month) (Day) (Year)

ADDRESS: (Street) (City)

(State) (Zip Code)

Please give current home address

TELEPHONE: (Home) (Business)

During the last three years, have you been convicted of a felony or misdemeanor (other than minor traffic violation); entered a plea of guilty; entered a plea under a first offender provision; been a defendant in a malpractice claim or had a professional license or membership sanctioned either publicly or privately?

No ? Yes ? If yes, attach copy of relevant documents.

In addition to this license, I hold the following other professional licenses: Not Applicable ?

License: ; ;

(Title) (Number) (State)

; ;

(Title) (Number) (State)

Have you had any disciplinary action taken against any professional license you hold? No ? Yes ?

Please list the names, addresses, and dates of the facilities in which you have been in direct management control over the last three years. Please list current facilities first.

Please list the names of all the AITs in which you precepted over the last three years. Please list current AITs first

Please submit a copy of your current resume and a copy of your Preceptor Recertification Training Certificate.

I hereby certify that the information listed on this application are true and correct to the best of my knowledge and belief.

In witness whereof, I set my hand and seal this day of , .

(Signature of Applicant)

Sworn to and Subscribed before me this day of , .

(Notary Public)

My Commission Expires County of State of

History

Author: Jacob L. Cureton, Jr.
Authority: Code of Ala. 1975, §34-20-9.
Amended: January 16, 2001; effective February 20, 2001.

Ala. Admin. Code r. 620-X-A-.18 AIT Program Outline - 200 Hour Program

Appendix A – Form 18

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

AIT PROGRAM OUTLINE - 200 HOUR

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NAME OF AIT: Date

(Title) (Last) (First) (Middle)

NAME OF FACILITY WHERE TRAINING IS TAKING PLACE:

ADDRESS:

TELEPHONE: FAX:

Proposed AIT Beginning Date: Proposed date of Completion:

CARE, SUPPORTS, AND SERVICES: (A minimum of 88 hours) TOTAL HOURS

NURSING SOCIAL SERVICES

DIETARY RECREATION/VOLUNTEER

MEDICAL RECORDS REHABILITATION SERVICES

MEDICAL/ALLIED HEALTH PHARMACEUTICAL PROGRAM

OPERATIONS: (A minimum of 54 hours) TOTAL HOURS

ADMINISTRATION BUSINESS

ENVIRONMENT AND QUALITY: (A minimum of 52 hours) TOTAL HOURS

HOUSEKEEPING/LAUNDRY MAINTENANCE

OTHER (6 hours): TOTAL HOURS

TOTAL NUMBER OF HOURS IN AIT TRAINING PROGRAM

TO BE COMPLETED BY THE SUPERVISING LICENSED NURSING HOME ADMINISTRATOR:

I certify that the AIT whose signature appears below has agreed to complete this AIT program of hours under my personal supervision.

(Signature of Preceptor)

AL NHA License #

(Signature of AIT)

History

Author: Lana Davis, Chairman
Authority: Code of Ala. 1975, §34-20-9.
Amended: January 16, 2001; effective February 20, 2001. Amended: Filed September 11, 2003; effective October 16, 2003. Amended: Filed July 21, 2017; effective September 4, 2017. Amended: Published January 31, 2022; effective March 17, 2022.

Ala. Admin. Code r. 620-X-A-.19 Certification Of Program Completion - 200 Hour Program

Appendix A – Form 19

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

CERTIFICATION OF PROGRAM COMPLETION - 200 HOUR PROGRAM

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NAME: Date

(Title) (Last) (First) (Middle)

NAME OF FACILITY WHERE TRAINING IS TAKING PLACE:

ADDRESS:

TELEPHONE: FAX:

DATE PROGRAM BEGAN: DATE PROGRAM COMPLETED:

CARE, SUPPORTS, AND SERVICES: (A minimum of 88 hours) TOTAL HOURS

OPERATIONS: (A minimum of 54 hours) TOTAL HOURS

ENVIRONMENT AND QUALITY: (A minimum of 52 hours) TOTAL HOURS

OTHER (6 hours): TOTAL HOURS

TOTAL NUMBER OF HOURS IN AIT TRAINING PROGRAM

TO BE COMPLETED BY THE SUPERVISING LICENSED NURSING HOME ADMINISTRATOR:

I certify that the AIT whose signature appears below has satisfactorily completed this AIT program of hours under my personal supervision.

Narrative evaluation of suitability for licensure as a nursing home administrator:

(Signature of Preceptor)

AL NHA License #

(Signature of AIT)

History

Author: Lana Davis, Chairman
Authority: Code of Ala. 1975, §34-20-9.
Amended: January 16, 2001; effective February 20, 2001. Amended: Filed September 11, 2003; effective October 16, 2003. Amended: Filed July 21, 2017; effective September 4, 2017. Amended: Published January 31, 2022; effective March 17, 2022.

Ala. Admin. Code r. 620-X-A-.20 AIT Program Outline - 500 Hour Program

Appendix A – Form 20

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

AIT PROGRAM OUTLINE - 500 HOUR

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NAME OF AIT: Date

(Title) (Last) (First) (Middle)

NAME OF FACILITY WHERE TRAINING IS TAKING PLACE:

ADDRESS:

TELEPHONE: FAX:

Proposed AIT Beginning Date: Proposed date of Completion:

CARE, SUPPORTS, AND SERVICES: (A minimum of 220 hours) TOTAL HOURS

NURSING SOCIAL SERVICES

DIETARY RECREATION/VOLUNTEER

MEDICAL RECORDS REHABILITATION SERVICES

MEDICAL/ALLIED HEALTH PHARMACEUTICAL PROGRAM

OPERATIONS: (A minimum of 135 hours) TOTAL HOURS

ADMINISTRATION BUSINESS

ENVIRONMENT AND QUALITY: (A minimum of 130 hours) TOTAL HOURS

HOUSEKEEPING/LAUNDRY MAINTENANCE

OTHER (15 hours): TOTAL HOURS

TOTAL NUMBER OF HOURS IN AIT TRAINING PROGRAM

TO BE COMPLETED BY THE SUPERVISING LICENSED NURSING HOME ADMINISTRATOR:

I certify that the AIT whose signature appears below has agreed to complete this AIT program of hours under my personal supervision.

(Signature of Preceptor)

AL NHA License #

(Signature of AIT)

History

Author: Lana Davis, Chairman
Authority: Code of Ala. 1975, §34-20-9.
New Form: January 16, 2001; effective February 20, 2001. Amended: Filed September 11, 2003; effective October 16, 2003. Amended: Filed July 21, 2017; effective September 4, 2017. Amended: Published January 31, 2022; effective March 17, 2022.

Ala. Admin. Code r. 620-X-A-.21 Certification Of Program Completion - 500 Hour Program

Appendix A – Form 21

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama 36106

(334) 271-2342

CERTIFICATION OF PROGRAM COMPLETION - 500 HOUR PROGRAM

(Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

NAME: Date

(Title) (Last) (First) (Middle)

NAME OF FACILITY WHERE TRAINING IS TAKING PLACE:

ADDRESS:

TELEPHONE: FAX:

DATE PROGRAM BEGAN: DATE PROGRAM COMPLETED:

CARE, SUPPORTS, AND SERVICES: (A minimum of 220 hours) TOTAL HOURS

OPERATIONS: (A minimum of 135 hours) TOTAL HOURS

ENVIRONMENT AND QUALITY: (A minimum of 130 hours) TOTAL HOURS

OTHER (15 hours): TOTAL HOURS

TOTAL NUMBER OF HOURS IN AIT TRAINING PROGRAM

TO BE COMPLETED BY THE SUPERVISING LICENSED NURSING HOME ADMINISTRATOR:

I certify that the AIT whose signature appears below has satisfactorily completed this AIT program of hours under my personal supervision.

Narrative evaluation of suitability for licensure as a nursing home administrator:

(Signature of Preceptor)

AL NHA License #

(Signature of AIT)

History

Author: Lana Davis, Chairman
Authority: Code of Ala. 1975, §34-20-9.
New Form: January 16, 2001; effective February 20, 2001. Amended: Filed September 11, 2003; effective October 16, 2003. Amended: Filed July 21, 2017; effective September 4, 2017. Amended: Published January 31, 2022; effective March 17, 2022.

Ala. Admin. Code r. 620-X-A-.22 Fee Schedule

Appendix A – Form 22

ALABAMA BOARD OF EXAMINERS OF

NURSING HOME ADMINISTRATORS

FEE SCHEDULE

EFFECTIVE 1/31/2010

STATE (RECIPROCITY) WRITTEN EXAM $350.00

RENEWAL $125.00

APPLICATION $150.00

EMERGENCY PERMIT $750.00

ORIGINAL LICENSE $150.00

AIT APPLICATION (200-1000 HR) $100.00

AIT APPLICATION (2000 HOUR) $150.00

PRECEPTOR CERTIFICATION $100.00

PRECEPTOR RECERTIFICATION $100.00

LATE RENEWAL PENALTY $400.00

RECIPROCITY QUESTIONNAIRE $75.00

INACTIVE REACTIVATION FEE $400.00

BAD CHECK RETURN FEE $ 25.00

COPIES (PER PAGE) $1.00 (per page 1-25)

$0.25 (per page 26+)

History

Author: Pam Penland, Chairman
Authority: Code of Ala. 1975, §34-20-7.
New Form: Filed December 8, 2006; effective January 12, 2007. Amended: Filed December 10, 2009; effective January 14, 2010.

Ala. Admin. Code r. 620-X-A-.23 Public Records Request Form

History

Author: Katrina G. Magdon, Executive Secretary
Authority: Code of Ala. 1975, §34-20-5.
New Rule: Published July 31, 2023; effective September 14, 2023.

Alabama Administrative Code Chapter 620-X-A — Appendix A Forms

620 Alabama Board of Examiners of Nursing Home Administrators

Ala. Admin. Code r. 620-X-A-.01 Complaint Form

Ala. Admin. Code r. 620-X-A-.02 Oral Examination Form (Repealed 2/20/01)

Ala. Admin. Code r. 620-X-A-.03 Application For License As A Nursing Home Administrator

Ala. Admin. Code r. 620-X-A-.04 Application For Renewal Of NHA Nursing Home Administrator

Ala. Admin. Code r. 620-X-A-.05 Reciprocity Questionnaire

Ala. Admin. Code r. 620-X-A-.06 Course Approval Form

Ala. Admin. Code r. 620-X-A-.07 Application For Administrator-In-Training

Ala. Admin. Code r. 620-X-A-.08 Application For Preceptor

Ala. Admin. Code r. 620-X-A-.09 Application For Facility Training Site

Ala. Admin. Code r. 620-X-A-.10 AIT Program Outline - 1000 Hour Program

Ala. Admin. Code r. 620-X-A-.11 AIT Program Outlined - 2000 Hour Program

Ala. Admin. Code r. 620-X-A-.12 Certification Of Program Completion - 1000 Hour Program

Ala. Admin. Code r. 620-X-A-.13 Certification Of Program Completion - 2000 Hour Program

Ala. Admin. Code r. 620-X-A-.14 AIT Quarterly Report Form

Ala. Admin. Code r. 620-X-A-.15 Application For Temporary Manager (Repealed 4/17/12)

Ala. Admin. Code r. 620-X-A-.16 Application For Preceptor Recertification

Ala. Admin. Code r. 620-X-A-.18 AIT Program Outline - 200 Hour Program

Ala. Admin. Code r. 620-X-A-.19 Certification Of Program Completion - 200 Hour Program

Ala. Admin. Code r. 620-X-A-.20 AIT Program Outline - 500 Hour Program

Ala. Admin. Code r. 620-X-A-.21 Certification Of Program Completion - 500 Hour Program

Ala. Admin. Code r. 620-X-A-.22 Fee Schedule

Ala. Admin. Code r. 620-X-A-.23 Public Records Request Form

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