Appendix A – Form 13

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama  36106

1. (334) 271-2342

   CERTIFICATION OF PROGRAM COMPLETION - 2000 HOUR PROGRAM

   (Please print clearly or type all answers - if there is not sufficient space, use additional sheets and number accordingly).

   NAME:                                                        Date

   (Title)     (Last)         (First)     (Middle)

   NAME OF FACILITY WHERE TRAINING IS TAKING PLACE:

   ADDRESS:

   TELEPHONE:                                    FAX:

   DATE PROGRAM BEGAN:                       DATE PROGRAM COMPLETED:

   CARE, SUPPORTS, AND SERVICES:  (A minimum of 880 hours)         TOTAL HOURS

   OPERATIONS:  (A minimum of 540 hours)                           TOTAL HOURS           

   ENVIRONMENT AND QUALITY: (A minimum of 520 hours)               TOTAL HOURS           

   OTHER (60 hours):                                               TOTAL HOURS           

   TOTAL NUMBER OF HOURS IN AIT TRAINING PROGRAM

   TO BE COMPLETED BY THE SUPERVISING LICENSED NURSING HOME ADMINISTRATOR:

   I certify that the AIT whose signature appears below has satisfactorily completed this AIT program of                   hours under my personal supervision.

   Narrative evaluation of suitability for licensure as a nursing home administrator:

   (Signature of Preceptor)

   AL NHA License #

   (Signature of AIT)

Author: Lana Davis, Chairman

Statutory Authority: Code of Ala. 1975, §34-20-9.

History: Amended: January 16, 2001; effective February 20, 2001. Amended: Filed September 11, 2003; effective October 16, 2003. Amended: Filed July 21, 2017; effective September 4, 2017. Amended: Published January 31, 2022; effective March 17, 2022.