Free 49845.FH11 - Indiana

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APPLICATION FOR PRECEPTOR
State Form 49845 (R4 / 11-08) Approved by State Board of Accounts, 2008

INDIANA STATE BOARD OF HEALTH FACILITY ADMINISTRATORS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected]

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Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given.

APPLICATION FEE: DATE FEE PAID: RECEIPT NUMBER: PRECEPTOR NUMBER: DATE ISSUED: DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name (last, first, middle, maiden) Residential address (number and street or rural route) City, state, and ZIP code Telephone number (Daytime) Date of birth (month, day, year) Birth place Original issuance date (month, day, year) Expiration date (month, day, year) Facility telephone number Email address *Social Security number

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RCA / HFA license number Name of training facility Address of facility (number and street) City, state, and ZIP code

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Type of facility

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ADMINISTRATOR-IN-TRAINING INFORMATION
Name of A.I.T. (last, first, middle, maiden) Address of A.I.T. (number and street) City, state, and ZIP code

WORK EXPERIENCE List below all of your work experience for the past three (3) years, starting with your present employment. INCLUDE YOUR EMPLOYER, POSITION, TYPE OF BUSINESS, PERIOD OF TIME WORKED, DUTIES, TYPE OF FACILITY (SNF, ICF, ETC.) AND NUMBER OF BEDS IN THE FACILITY.

(Continued on the reverse side)

WORK EXPERIENCE (continued) List all other related experience pertaining to the health facility, administration, and/or other related areas:

Have you ever been qualified as a Preceptor in another state?

Yes
If yes, list the state, date of issuance and expiration date.

No

If your answer is yes to any of the following, explain fully in a sworn affidavit, including all related details. Include the violation, location, date and disposition. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to the application. 1) 2) 3) 4) Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? Have you ever been denied a license, certificate, registration or permit to practice as a health facility administrator or any regulated health occupation in any state or country? Are you now, or have you ever been treated for drug or alcohol abuse? Have you ever been convicted of, pled guilty or nolo contendre to A. A violation of any Federal, State, or local law relating to the use, manufacturing, distribution or dispensing of controlled substances or drug addiction? B. To any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines.) Have you ever been denied staff membership or privileges in any hospital, or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? Have you ever been terminated, reprimanded, disciplined or demoted in the scope of your practice as any health care professional?
VERIFICATION

Yes Yes Yes Yes Yes

No No No No No

5) 6)

Yes Yes

No No

I hereby swear or affirm under the penalties of perjury, that the above statements made in this application including all attachments are true, complete and correct.
Signature of applicant Date (month, day, year)