INSTRUCTOR Form

Adult Family Homes, Assisted Living Facilities, and Enhanced Services Facilities

Submit this form to offer long term care (LTC) worker training course(s) to your staff in Dementia and/or

Mental Health specialty training. The instructor must sign this form.

Section 1: General Information
Instructor Name:	Date of birth:
Phone:	( ) -	Cell:	( ) -
Email:
Facility Name:
Qualifications:	I am twenty-one (21) years of age or older	Yes No
I have not had a professional health care, adult family home, assisted living facility, or social services license or certification revoked in Washington state.	Yes No
Education:	Check the highest level of education you have completed:
High School or equivalent	Associates	Bachelors	Masters	PH.D.

Section 2: Work Experience (select highest level of experience)
You are a registered nurse with work experience within the last five years with the elderly or persons with disabilities requiring long-term care in a community setting; or	Yes No
You have an associate degree or higher degree in the field of health or human services and six months professional or caregiving experience within the last five years in a community based setting such as an adult family home, assisted living;	Yes No
You have a high school diploma, or equivalent, and one year of professional or caregiving experience within the last five years in a community based setting such as an adult family home, assisted living facility, supported living through DDA, or in-home care setting.	Yes No

Section 3: Teaching Experience (select highest level of experience)
You have one hundred hours of experience teaching adults on topics directly related to the basic training; or	Yes No
You have forty hours of teaching while being mentored by an instructor who meets these qualifications; or	Yes No
You have forty hours of informal teaching experience, and: You are able to name three adult learning principles. Yes No You are able to describe a self-improvement plan to further develop your teaching ability. Yes No	Yes No

Section 4: Training and Caregiving
You have 1) attended an adult education class, 2) attended the special training class you are requesting to teach, and 3) have sent your certificates of completion to DSHS.	Yes No
You have experience or training in conducting assessments and competency testing.	Yes No
You are experienced in caregiving practices and capable of demonstrating competency with respect to teaching the course content or units being taught.	Yes No

Section 5: Certification
I certify and understand that: The information provided in this application is true, complete and accurate. Untruthful or misleading answers are cause for rejection of this application.
Name: Date: / /