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Commonwealth of Massachusetts

Executive Office of Health and Human Services

Department of Public Health

Division of Health Professions Licensure

Board of Registration of Nursing Home Administrators

239 Causeway Street, Suite 500

Boston, MA 02114

800-414-0168

617-973-0800

www.mass.gov/dph/boards

Instructions for Administrator in Training [AIT] Application

Nursing Home Administrator

Please read these instructions carefully. All AIT supporting materials must be submitted at the same time. Applications will not be reviewed by the Board until all documentation has been received.

All requested information must be provided; failure to provide requested information may result in a delay in processing of application. Incomplete applications will be returned to applicant.

The Following Documents Must be Submitted Together by Mail:

1. A completed application with notary signature, 2x2 color passport photo and a check or money order payable to the Commonwealth of Massachusetts for $75.00.

2. A signed Criminal Offender Record Information Request Form (CORI).

3. A request from the applicant for the proposed AIT internship, including the name of the preceptor, the facility at which the training will take place, number of beds and any requests for credit for academic and/or professional experience.

4. A letter from the proposed preceptor to the Board requesting that he/she be approved as the preceptor. The preceptor must be a Massachusetts licensed administrator in good standing with at least five years of Nursing Home Administration experience.

5. A detailed outline of the proposed Internship must be submitted.

NOTE: the Preceptor Guidelines cannot be submitted as the internship outline.

Once approved, the preceptor must submit 3 and 6 months progress reports directly to the Board of Registration of Nursing Home Administrators, Division of Health Professions Licensure, 239 Causeway Street, Suite 500, Boston, MA 02114.

6. A signed agreement between the preceptor and the candidate. The agreement must state where the training is to be held, number of beds in the facility, and if it is a multi-level or skilled facility.

7. A current resume.

The Following Documents Must be Received by the Board in Signed, Sealed Envelopes:

8. Official transcripts in signed, sealed envelopes for all undergraduate programs/degrees and any other post-secondary programs/degrees. When requesting official transcripts, please inform each school’s registrar that the transcript must be complete and indicate the degree and date conferred in mm/dd/yyyy format. Transcripts may be sent directly to the Board by the institutions.

9. Verification of licensure status, in signed, sealed envelopes, from any state or jurisdiction in which you now or have previously held any professional license. Verifications must be sent directly to the Board by the state or jurisdiction.

10. If applicant currently holds or has previously held any professional license, a National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank Self-Query [original] must be submitted with the application. To request a self-query, please contact the National Practitioner Data Bank at 1-800-767-6732 or at www.npdb-hipdb.hrsa.gov. Include the original report with this application and be sure to keep a copy for your records.

11. The Board will notify AIT candidates in writing if the proposed program is approved and the start date of the program.

12. At the completion of the AIT program, the Preceptor must submit a final report to the Board for approval. When your AIT program has been completed and approved by the Board, you will be notified by letter of the procedure for taking the licensure examination. You will also be notified to submit the Administrator Affidavit Certificate of Internship Training.

13. Applications are void if requirements for the administrator in training program are not met within one (1) year from the date of Board receipt of this application. All fees are non-refundable and non-transferable. Submission of a completed application acknowledges that the applicant understands and agrees to provisions herein.

14. Applications must be submitted on single-sided pages.

15. Retain a copy of the complete application and supporting documentation for your records.

IMPORTANT INFORMATION

An administrator in training applicant/trainee must notify the Board in writing of any changes in the applicant/trainee’s information within thirty (30) days of their occurrence, including but not limited to any change of address and any name change.

An application is no longer valid if requirements for administrator in training are not met within one (1) year from the date of Board receipt. All fees are non-refundable and non-transferable.

Your address is a PUBLIC RECORD that is available to anyone who requests it. Address changes may be done online at the board’s website www.mass.gov/dph/boards or you may obtain a form online to submit to the Board’s office.


The address of record is where the Board mails all correspondence.


Retain a copy of the completed application and other documentation for your records. Employers may require that you provide them with a copy.

Answers to many questions may be found on the Board’s website (www.mass.gov/dph/boards). Statutes and regulations governing the AIT Program may be found on the website; they are also available for purchase from the State House Bookstore, Massachusetts State House, Room 116, Boston, MA 02108, 617-727-2834.

For further information, please contact the Board office at 1-800-414-0168.

Commonwealth of Massachusetts

Executive Office of Health and Human Services

Department of Public Health

Division of Health Professions Licensure

Board of Registration of Nursing Home Administrators

239 Causeway Street, Suite 500

Boston, MA 02114

800-414-0168

617-973-0800

www.mass.gov/dph/boards

Application and Checklist

Nursing Home Administrator In Training Program

All requested information must be provided; failure to provide requested information may result in a delay in processing of application. Incomplete applications will be returned to applicant.

The application for the Administrator in Training [AIT] includes the following documents:

  • Application form and supporting documentation

  • Preceptor Guidelines

The following must be included for a complete application. Please complete and enclose this checklist with your application. Applications will not be reviewed by the Board until they are complete. Applications must be mailed to the above address in one envelope. Retain a copy of the completed application for your records.

□ Completed application form including notary signature, a 2x2 passport sized color photo and a

check or money order payable to the Commonwealth of Massachusetts for $75.00.

□ A signed Criminal Offender Record Information Request Form (CORI).

□ Letter from the candidate to the Board requesting approval to be an AIT. This letter must
include the name of the proposed preceptor, the facility where the AIT will take place and any
requests for credit for academic and/or work experience.

□ Letter from Preceptor to Board requesting that he/she be approved as the preceptor. The
preceptor must be a MA licensed administrator in good standing with at least five years of
nursing home administrator experience.

□ Detailed outline of the proposed internship.

□ Letter of agreement between the candidate and the preceptor stating that they agree to the
terms of the proposed internship.

□ Resume


□ Official transcripts in signed, sealed envelopes for all undergraduate programs/degrees, other post-secondary programs/degrees. When requesting official transcripts, please inform each school’s registrar that the transcript must be complete and indicate the degree and date
conferred in mm/dd/yyyy format.


□ Verification of licensure status, in signed, sealed envelopes, from any state or jurisdiction in which you now or have previously held any professional license. Verifications must be sent directly to the Board by the state or other jurisdiction.

□ If you hold, or have ever held, a professional license, you must request and submit a National
Practitioner Data Bank-Healthcare Integrity and Protection Data Bank Self-Query. To request a
Self-Query, please contact the National Practitioner Data Bank at 1-800-767-6732 or at
. Include the original report with this application; make a copy for your
records.

NOTE: If you do NOT hold and have never held a professional licenses in any other
state, you do not need to submit a National Practitioner Data Bank self-query.

□ Application must be submitted on single-sided paper.

Commonwealth of Massachusetts

Executive Office of Health and Human Services

Department of Public Health

Division of Health Professions Licensure

Board of Registration of Nursing Home Administrators

239 Causeway Street, Suite 500

Boston, MA 02114

617-973-0806

www.mass.gov/dph/boards

All Questions Must Be Completed

Administrator in Training Program (AIT) Application Fee - $75.00

1. Applicant Name:____________________________________________________________________

2. Maiden Name/Other Name:__________________________________________________________

3. Address of Record:_________________________________________________________________

No. Street Apt

_____________________________________________________________________________________
City State Zip Code

4. Most Recent Previous Address: ______________________________________________________
(different to Address of Record) No. Street Apt

_____________________________________________________________________________________
City State Zip Code

5. Telephone Number: Day:_______________________ Cell:___________________________

6. _______/_______/______

Date of Birth (mm/dd/yyyy) Place of Birth (city/state/country)

Height: ____ Feet ____ Inches Weight: Lbs. Eye Color:

Sex: M F (Circle One) Mother’s Maiden Name:

Email:

7. Social Security Number (SSN) (disclosure is mandatory): / /

Pursuant to G.L. c. 62C, s. 47A, the Division of Health Professions Licensure is required to obtain your SSN and forward it to the Massachusetts Department of Revenue. The Department of Revenue will use your SSN to ascertain whether or not you are in compliance with Massachusetts tax laws (G.L. c. 62C, s. 47A) and child support laws (G.L. c. 119A, s.16).

FOR BOARD USE ONLY

Application Number: _______________ Receipt Number: _____________________

AIT Number: _____________________

Education



8. Bachelor’s Degree School Name/Location: ____________________________________________


______________________________________________________________________________________


Degree: ____________________________ Date Awarded: _____/_____/______

Submit official transcript in a signed, sealed envelope. Transcripts must be mailed directly to the Board.



9. Other post-secondary Institution(s)/Location(s): _____________________________________


_____________________________________________________________________________________


Degree: Date Awarded: /_______/_______
(mm/dd/yyyy)

Submit official transcript in a signed, sealed envelope. Transcripts must be mailed directly to the Board.

10. Please list additional post-secondary institutions on a separate sheet and request that transcripts be submitted directly to the Board as noted above.

Verification Of Other Licenses/Board Certifications

11. List below all other professional licenses and board certifications ever held; include all states and jurisdictions

I do not currently hold and have never held a professional license or certification in any state or jurisdiction.

Issuing State/ Jurisdiction Profession License/Certification Number

_______________ _______________ ________________

Applicants must arrange for official documentation of current license status from each state or jurisdiction to be mailed directly to the Board.

Questions

If you answer "YES" to any of the following questions please attach a separate sheet explaining the circumstances.

12. Have you ever been denied a license, or ever withdrawn or attempted to withdraw an application, for any professional license in the United States or any country or foreign jurisdiction?

Yes □ No □

13. Has any licensing or certification board, government authority, hospital or health care facility or professional association located in the United States or any country or foreign jurisdiction taken any disciplinary action against you?

Yes □ No □

14. Are you the subject of any pending disciplinary action by any licensing or certification board, government authority, hospital or health care facility or professional association located in the United States or any country or foreign jurisdiction?

Yes □ No □

15. Have you ever voluntarily surrendered or resigned any professional license or board certification in the United States or any country or foreign jurisdiction?
Yes No

16. Have you ever been arrested, charged, arraigned, indicted, prosecuted, convicted or been the subject of any criminal investigation or any court proceeding in relation to any criminal violation? Do not report minor violations for which a fine of $100 or less was imposed.

Yes □ No □

17. Have you ever been court martialed or other than honorably discharged from the armed services (military) of the United States or of any country or foreign jurisdiction?

Yes □ No □

Release

I hereby authorize all hospitals, institutions, credentialing agencies, organizations, personal physicians, employers (past and present), business and professional associates (past and present), and all government agencies and entities (local, state, federal, or foreign) to release to the Board of Registration of Nursing Home Administrators any information, files or records requested by the Board in connection with the processing of my application. I further authorize the Board of Registration of Nursing Home Administrators to release information contained in this application in association with its processing.

Affidavit of applicant

To the best of my knowledge and belief, I have filed all state tax returns and paid all state taxes required by state law and do not owe child support.

I understand that the Board is certified by the Massachusetts Criminal History Systems Board for access to Criminal Offender Record Information (CORI), including conviction and pending criminal case data. As an applicant for the AIT program I understand that a CORI check may be conducted by the Board for conviction and pending criminal case information only and that the CORI results will not necessarily disqualify me.

I understand that I am responsible for reading and understanding the laws and regulations governing practice as an administrator in training in Massachusetts and I hereby agree to comply with such laws and regulations.

I understand that this application for the administrator in training program shall be deemed no longer valid if requirements are not met within one (1) year from the date of Board receipt. I also understand that fees are non-refundable and non-transferable.

I certify, under the pains and penalties of perjury, that the information I have provided pursuant to this application is truthful and accurate. I understand that any failure to provide truthful and accurate information in connection with this application be grounds for the Board of Registration of Nursing Home Administrators to deny the application; and to suspend or revoke permission to participate in the program, all in accordance with Massachusetts law.

Applicant Signature _______________________________ Date ________________


Print Name _______________________________________

Attach a recent color

2x2 passport

photo

Notary Name: ______________________________


Commission Expires: _______________________ [Seal]

Include a nonrefundable , nontransferable fee of $75.00 (check or money order ) payable to the Commonwealth of Massachusetts


BORNHA

G

Commonwealth of Massachusetts

Executive Office of Health and Human Services

Department of Public Health

Division of Health Professions Licensure

239 Causeway Street, Suite 500

Boston, MA 02114

Board of Registration of Nursing Home Administrators

(617) 973-0800


DEVAL L. PATRICK

GOVERNOR

TIMOTHY P. MURRAY

LIEUTENANT GOVERNOR

JUDYANN BIGBY, MD

SECRETARY

JOHN AUERBACH

COMMISSIONER

JEAN K. PONTIKAS

DIRECTOR

CORI REQUEST FORM

The Massachusetts Board of Registration of Nursing Home Administrators (Board) has been certified by the Criminal History Systems Board for access to Criminal Offender Record Information (CORI), including conviction and pending criminal case data. As an applicant to the Board for the AIT Program, I understand that the Board may conduct a CORI check for authorized data using the information provided below and that any CORI check results will not necessarily disqualify me. I hereby attest that the information I have provided below is true and accurate to the best of my knowledge and belief.

___________________________________________________ ____________________________

License Applicant's Signature Date
______________________________________________________________________________________________
Last Name First Name Middle Name

_____________________________________________ ________________________________________

Maiden Name or Alias (If Applicible) Place of Birth (city, town, country)

____________________________________ ________________________________ __________________

Date of Birth (dd/mm/yyyy) Social Security Number ID Theft Index PIN

(Requested but not Required) (If Applicable)

___________________________________

Mother’s Maiden Name

Current and Former Addresses: ____________________________________________________________________

­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________________________________________________________________________________________


Sex: ____ Height: ______ Weight: ______ Eye Color: ________ State Driver’s License___________________




For Official Use Only
CORI Requested By: _____________________________________ __________________________

Signature of CORI Authorized Employee Print Name

Board of Registration of Nursing Home Administrators
Commonwealth of Massachusetts

Preceptor Guidelines

Administrator in Training

I. General Administration
Corporate Structure

Methods of Supervision

Pre-Admission and Admission of
Patient
Business Correspondence
Employer-Employee Relations
State and Federal Regulation
Relationships with Dept. of Public
Welfare
Financial Records

II. Nursing
Knowledge of Nursing Functions
The Director of Nurses, RN’s, LPN’s &
Aides
Physician Responsibilities
Tour of Stations

Medical Records

Drug Routines & Requirements

III. Dietary
The Dietary Staff

Food Preparation & Services
Record Keeping
In-Service Education
Staff Meetings

IV. Housekeeping, Maintenance &
Laundry
Philosophy and Goals of Department
Administering Duties
Record Keeping
Inspections
Scheduling of Personnel
Cleaning and Maintenance Techniques

V. Social Services & Consultant
Admission Procedures
Transfer Procedures
Discharge Procedures
Family Counseling
The Social Worker

The Physical Therapist
The Occupational Therapist
The Dietician

VI. Personnel Management
Philosophy and Goals of Department

Personnel Policies, Procedures, &
Requirements
Counseling & Coordination
Problem Solving/Union Relations
Wages & Benefits

VII. Business Office
Methods of Bookkeeping
Billing Procedures
Payroll

Purchasing Procedures
Insurance Consideration
Medicare/Medicaid, Commercial, VA,
private sources of reimbursement and
regulations regarding each source.

Application for Administrator in Training

Board of Registration of Nursing Home Administrators

Revised 2-2012 Page 12 of 12



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