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Secondary Partners - Annual Nurse Aide Report 2020-21

Nurse Aide Reporting Form

The following information needs to submitted by June 1, 2021 or before you leave for the summer. Failure to submit a report in a timely manner will result in your program being placed on a Plan of Correction. Please contact Vicki Weaver at vicki.weaver@education.ky.gov if you experience any difficulty or have any questions concerning this report.

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1. Please enter your School Contact Information

School Name

First Name

Last Name

Title

Street Address

Apt/Suite/Office

City

State

Zip

Email Address *This question is required. This question requires a valid email address.

Phone Number

Principal/Administrator's First Name

Principal/Administrator's Last Name

Principal/Administrator's E-mail

2. Please enter your training provider approval number(s):

	Secondary Training Number
	Adult Training Number

3. Please enter your Facility Number

	Facility Number

4. RN Primary Instructor Information

Primary Instructor First Name

Primary Instructor Last Name

Email Address

KBN License #

Years of LTC Experience

5. Nurse Aide Instructor InformationState and Federal regulation requires that nurse aide instructruction be performed by or under the general supervision of a registered nurse who has a minimum of two (2) years experience, at least one (1) of which shall be in LTC. This information is required to be submitted in the annual report. In compliance with these requirements, please provide the following information.

	Instructor Name	KBN License #	Yes
	Instructor Name	KBN License #	One Year LTC Experience
NA Instructor #1	Instructor Name	KBN License #
NA Instructor #2	Instructor Name	KBN License #
NA Instructor #3	Instructor Name	KBN License #
NA Instructor #4	Instructor Name	KBN License #

6. Clinical Site InformationPlease list out all clinical sites used in this reporting period. Each program is required to verify the status of a facility prior to each class entering the facility for a clinical experience.

	Clinical Site Name	Yes	Date Clinical MOA Signed
	Clinical Site Name	Civil Money Penalty or Extended Survey	Date Clinical MOA Signed
Clinical Site #1	Clinical Site Name		Date Clinical MOA Signed
Clinical Site #2	Clinical Site Name		Date Clinical MOA Signed
Clinical Site #3	Clinical Site Name		Date Clinical MOA Signed
Clinical Site #4	Clinical Site Name		Date Clinical MOA Signed
Clinical Site #5	Clinical Site Name		Date Clinical MOA Signed
Clinical Site #6	Clinical Site Name		Date Clinical MOA Signed

7. Please enter the following numbers for your secondary training program:

Total Number Trained and qualified to take the SRNA exam

Total Number Tested 1st Attempt - retakes are not to be counted.

Total Number Passing 1st Attempt - retakes are not to be counted

Passing Rate 1st Attempt - retakes are not to be used for calculations This question requires a valid percent format.

8. Please enter the following numbers for your adult training program if applicable, otherwise skip this section.

Total Number Trained and qualified to take the SNRA exam

Total Number Tested 1st Attempt - retakes are not to be counted

Total Number Passing 1st Attempt - retakes are not to be counted

Passing Rate 1st Attempt - retakes are not to be used for calculations This question requires a valid percent format.

9. Comments or additional information Please feel free to enter any comments, suggestions, feedback, or additional evaluator/instructor/clinical site information in the space below.

Please electronically sign acknowledging accurate completion of this form. *This question is required.

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