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Nurse Aide Training Program - Request for Change in Hours

A nurse aide training program must satisfy the requirements under 43 CFR 483, Subpart D; Wis. Stat. § 146.40, and Wis. Admin. Code ch. DHS 129 to qualify for approval by the Department. A program must submit an application to the Department for review and approval determination. The Social Security Act, as amended by the federal Omnibus Budget Reconciliation Act of 1987, authorizes the State to review and determine eligibility for nurse aide instructional programs under the requirements of the Medicare and Medicaid programs.


Instructions:
  • Complete one application for each program you intend to modify or add to.
  • All items on the application must be answered completely. Incomplete applications will not be considered.
  • You will receive a PDF with your responses once you have completed the survey; please retain this for your records.
  • The Department will approve or deny the application in writing within 90 days of receiving the completed application.

Nurse aide training programs currently approved to operate programs with at least 120 hours of instruction may apply for:
  1. Application for new 75-hour-minimum program, which is in addition to existing program of at least 120 hours.
  2. Modification to their current program (application for 75-hour-minimum training program to replace existing program of at least 120 hours).
 
Please indicate the purpose of your request (if you will be making multiple program modification/addition requests, please complete a separate survey for each request): *This question is required.
Contact Information  *This question is required.
This question requires a valid email address.
This application is only for those programs that are modifying curricular hours. Any changes to other application components listed below must be reported separately, via a substantial change form, to the Nurse Aide Training Consultant, DHSWIDQA_NATCEP@dhs.wisconsin.gov .

Nurse Aide Training Program Application Components

I.   General Information
A. Applicant Information
B. Authorized Person Information
C. Program Information
D. Fit and Qualified Document
II.  Program Operation
A. Classroom Setting
B. Clinical Practice Setting
C. Record Retention
D. Bias Free Program
E. Floor Plan
F. Performance Records
G. Program Information
H. Supervision
I. Successful Program Completion
J. Program Evaluation
K. Organizational Chart
L. Program Supplies
III. Primary Instructor/Program Trainer Qualifications
A. Primary Instructor
B. Program Trainer
C. Instructor to Trainee Ratio
0%