Form F-62224 - Form For Notice Of Substantial Change Nurse Aide Training Program
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1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
42 CFR 483.75, Subpart D
F-62224 (Rev. 11/08)
HFS 129, Wis. Admin. Code
NOTICE OF SUBSTANTIAL CHANGE
NURSE AIDE TRAINING PROGRAM
•
The purpose of this form is to provide the Division of Quality Assurance (DQA) with information regarding a substantial change in
an approved nurse aide training program. Any substantial change must be reported to DQA in writing 10 days prior to the
implementation of the change. The substantial change must not be implemented until the change is approved by DQA. DQA
responds to all Notice of Substantial Change forms in writing.
•
“Substantial change” is defined as any change in the program designee, primary instructor, program trainer, curriculum, classroom
location, or clinical site.
•
Failure to provide this information may result in the suspension or revocation of the program’s certification or the imposition of a
plan of correction on the program, per HFS 129, Wis. Admin. Code.
•
If you have questions about the completion of this form, please contact the Office of Caregiver Quality at (608) 261-8328.
•
Submit this completed form to: Wisconsin Nurse Aide Training Consultant
Office of Caregiver Quality
P.O. Box 2969
Madison, WI 53701-2969
FAX: (608) 264-6340
•
Print neatly in BLACK INK or type.
Name - Program
Program Approval Number
CHANGE
Date (mm/dd/ccyy)
•
Program designee changed? If “yes,” indicate date of change and attach details, including name, telephone
number, and e-mail address.
Date (mm/dd/ccyy)
•
Primary instructor changed? If “yes,” indicate date of change and attach details, including, name, copy of current
RN license, resume, Social Security Number, home address, telephone number.
Date (mm/dd/ccyy)
•
Program trainer changed? If “yes,” indicate date of change and attach details.
•
Date (mm/dd/ccyy)
Program site (instructional or clinical) changed? If “yes,” indicate date of change and attach details, including
physical and mailing address, telephone number, and FAX number.
Date (mm/dd/ccyy)
•
Training curriculum changed? If “yes,” indicate date of change and attach details of curriculum change.
REASON FOR CHANGE (Identify page and section from attached application.)
PROGRAM REPRESENTATIVE
Name – Program Representative
Title
Telephone Number
FAX Number
Date Signed
SIGNATURE – Program Representative
DHS USE ONLY
Approved
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Approval Pending - Information Needed
Denied
Reason for Denial: _____________________________________________________________________________________________
Name – Reviewer
Title
Date Reviewed
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