In-service and Orientation programs are required for all Skilled Nursing Facilities (SNF) and Intermediate Care Facilities (ICF).
The following items must be submitted for application consideration:
Nurse Assistant Orientation Program Content (CDPH 278A) (PDF) (Revised 12/19)
Submit a lesson plan for a direct patient care skill that is taught during supervised clinical training included in the first 8 hours of the orientation.
Submit a copy of the orientation skills return demonstration record used to document the basic patient care clinical training from first 8 hours of the orientation.
In-Service Training Program (CDPH 278B) (PDF) (Revised 12/19)
Submit two lesson plans. The lesson must be for two different courses that you listed on your CDPH 278B form.
Submit a three-month in-service schedule for future months.
Submit a copy of the in-service sign-in sheet. It must include the following:
Name of the health facility
In-service course title
Date of in-service
In-service start time and end time
Instructor name (typed/printed) and instructor's signature
Participant's name (typed/printed) and participant's signature
Participant's CNA or HHA certification number
Submit a copy of the record keeping policy. It must include the following:
Which in-service records are maintained (sign-in sheets, lesson plans, written exam etc.)?
How long (4-year minimum) are the In-service records maintained?
Storage location address.
How records are stored (hard copy or digital)?
The title of the person responsible for the record keeping.
Facility Declaration of Participation in Approved Training Programs (CDPH 278C) (PDF) (Revised 01/20) - Required for Skilled Nursing Facilities (SNF) and Intermediate Care Facilities (ICF) only
If you are choosing Option 2: Nurse Assistant Pre-certification Training Contract on CDPH 278C, then Submit CDPH 278SC Sample Contract Template (PDF) (Revised 12/19)
Director of Staff Development Application (CDPH 279) (PDF) (Revised 04/19)
Note: Only send this for new DSD applicants. If a DSD is already approved for your facility, you don't need to resend this form for renewals.
Program Flexibility (CDPH 5000) (PDF) (Revised 04/08)
Contact Information Form (CDPH 193) (PDF) (Revised 12/19)