KCTCS Only - Annual Nurse Aide Report 2020-21

The following information needs to submitted by July 15, 2021. Also, by this date testing results for all students should be entered into PeopleSoft. The number of students trained and your first time test taker pass rate will be mined directly from PeopleSoft. You will not be asked to supply that information in this report.

You are able to add/edit this report throughout the year. Once you complete the survey you will receive a link that allows you to come back to your data.

Please contact Denise Welch at denise.welch@kctcs.edu if you experience any difficulty or have any questions concerning this report.

If viewing on an iPad, iPhone, Android phone, or similiar device, please view in landscape mode (turn your device sideways).

1. Please enter your College Contact Information

College 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

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

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.

6. Please enter the primary instructor for all nurse aide instructors that LACK the one (1) year of LTC experience.

7. 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	No	Date Clinical MOA Signed
	Clinical Site Name	Civil Money Penalty or Extended Survey		Date Clinical MOA Signed
Site #1	Clinical Site Name	Site #1: Civil Money Penalty or Extended Survey: Yes	Site #1: Civil Money Penalty or Extended Survey: No	Date Clinical MOA Signed
Site #2	Clinical Site Name	Site #2: Civil Money Penalty or Extended Survey: Yes	Site #2: Civil Money Penalty or Extended Survey: No	Date Clinical MOA Signed
Site #3	Clinical Site Name	Site #3: Civil Money Penalty or Extended Survey: Yes	Site #3: Civil Money Penalty or Extended Survey: No	Date Clinical MOA Signed
Site #4	Clinical Site Name	Site #4: Civil Money Penalty or Extended Survey: Yes	Site #4: Civil Money Penalty or Extended Survey: No	Date Clinical MOA Signed
Site #5	Clinical Site Name	Site #5: Civil Money Penalty or Extended Survey: Yes	Site #5: Civil Money Penalty or Extended Survey: No	Date Clinical MOA Signed
Site #6	Clinical Site Name	Site #6: Civil Money Penalty or Extended Survey: Yes	Site #6: Civil Money Penalty or Extended Survey: No	Date Clinical MOA Signed

8. Nurse Aide Evaluator InformationThe MOA with the Department of Medicaid Services requires that test evaluators be registered nurses with at lease one-year of experience in providing care for the elderly and that this information be submitted in the annual report. In compliance with these requirements, please provide the following information.

	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly	Evaluator #1	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #2	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #3	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #4	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #5	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #6	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #7	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #8	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #9	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #10	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #11	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #12	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #13	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #14	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #15	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #16	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #17	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #18	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #19	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly
Evaluator #20	Evaluator Name	KBN License #	Years of Experience in Caring for Elderly

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.

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

Clear

Signature of

	Instructor Name	KBN License #	Yes	No
	Instructor Name	KBN License #	One Year LTC Experience
Instructor #1	Instructor Name	KBN License #	Instructor #1: One Year LTC Experience: Yes	Instructor #1: One Year LTC Experience: No
Instructor #2	Instructor Name	KBN License #	Instructor #2: One Year LTC Experience: Yes	Instructor #2: One Year LTC Experience: No
Instructor #3	Instructor Name	KBN License #	Instructor #3: One Year LTC Experience: Yes	Instructor #3: One Year LTC Experience: No
Instructor #4	Instructor Name	KBN License #	Instructor #4: One Year LTC Experience: Yes	Instructor #4: One Year LTC Experience: No
Instructor #5	Instructor Name	KBN License #	Instructor #5: One Year LTC Experience: Yes	Instructor #5: One Year LTC Experience: No
Instructor #6	Instructor Name	KBN License #	Instructor #6: One Year LTC Experience: Yes	Instructor #6: One Year LTC Experience: No
Instructor #7	Instructor Name	KBN License #	Instructor #7: One Year LTC Experience: Yes	Instructor #7: One Year LTC Experience: No
Instructor #8	Instructor Name	KBN License #	Instructor #8: One Year LTC Experience: Yes	Instructor #8: One Year LTC Experience: No
Instructor #9	Instructor Name	KBN License #	Instructor #9: One Year LTC Experience: Yes	Instructor #9: One Year LTC Experience: No
Instructor #10	Instructor Name	KBN License #	Instructor #10: One Year LTC Experience: Yes	Instructor #10: One Year LTC Experience: No
Instructor #11	Instructor Name	KBN License #	Instructor #11: One Year LTC Experience: Yes	Instructor #11: One Year LTC Experience: No
Instructor #12	Instructor Name	KBN License #	Instructor #12: One Year LTC Experience: Yes	Instructor #12: One Year LTC Experience: No
Instructor #13	Instructor Name	KBN License #	Instructor #13: One Year LTC Experience: Yes	Instructor #13: One Year LTC Experience: No
Instructor #14	Instructor Name	KBN License #	Instructor #14: One Year LTC Experience: Yes	Instructor #14: One Year LTC Experience: No
Instructor #15	Instructor Name	KBN License #	Instructor #15: One Year LTC Experience: Yes	Instructor #15: One Year LTC Experience: No

KCTCS Only - Annual Nurse Aide Report 2020-21

Nurse Aide Reporting Form