Cdph 278r: Fill out & sign online

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Click ‘Get Form’ to open the cdph 279 form in the editor.
Begin by entering the Facility/School Name and Telephone Number. Ensure that this information is accurate for proper identification.
Fill in the Provider Identification Training Number, which is essential for tracking your application.
Select the Types of Training to be Offered by checking the appropriate boxes, such as Orientation and In-Service Training Programs or Nurse Assistant Training Program (NATP).
Complete the Applicant’s Name, Mailing Address, Telephone Number, and Email Address fields. If you have prior approval as an Instructor or DSD, include your number.
Provide your signature along with details about your employment hours and date employed as an Instructor or DSD.
If not previously approved, attach required documents like your resume and certificates of completion for any relevant courses.
Finally, ensure that both the Administrator/Owner and Director of Nursing/Program Director RN sign and date the form before submission.

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