The following agency information is required with your request for approval.
Agency Demographics Form:
One Agency Demographics Form is required for each license number (DAL Attachment 1):
1. Agency Name;
2. Agency Address;
3. Agency License Number;
4. Training Program Approval Type;
5. Address where testing, skills, and Supervised Practical Training (SPT) will be
6. Language(s) – Please note that prior Foreign Language approval is required;
7. Name of Nurse Instructors Responsible for Hybrid Training;
Attestations: The following are Operator/Administrator attestations required for Hybrid Training approval.
If your agency is requesting Hybrid Training approval for both PCA training and HHA training, both attestations are required:
1. PCATP Attestation (PCATPs Only, DAL Attachment 2);
2. HHATP Attestation (HHATPs Only, DAL Attachment 3);
Hybrid Training Program Schedule (DAL Attachment 4):
The schedule must include the content of the training program modules/units (didactic portion of training) and administration of written and (required and optional) skills performance evaluation.
The schedule must indicate if the session being held is online or in the skills laboratory. Additional topics may be included in the training, but they must be in addition to the minimum hourly requirement and may not substitute for required topics. The time allocated for each training topic, breaks and meals, tests, supervised practical training (SPT), and skills performance evaluations must be identified on the schedule. The day the certificates of completion are distributed to the trainees must also be included.
For HHATPs: A schedule is required for each training class type being offered through a hybrid approach: Full Training, Personal Care Aid Upgrading, and Certified Nurse Aide Transitioning.