Appendix A – Form 14

Alabama Board of Examiners of Nursing Home Administrators

4156 Carmichael Road, Montgomery, Alabama  36106

1. (334) 271‑2342

   AIT QUARTERLY REPORT FORM

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

   AIT reports are to be sent in every three months following the start of training.  Prior to the end of each three month period, a report form will be sent to you for completion.  The AIT report shall be used to list experience gained since the date your training started.

   NAME:                                                        Date

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

   NAME OF FACILITY WHERE TRAINING IS TAKING PLACE:

   THIS REPORT COVERS THE PERIOD FROM                        TO

   DURING THIS PERIOD I RECEIVED          HOURS OF AIT TRAINING AND I WORKED                          DAYS PER WEEK.

   For Additional Comments:  use reverse side of this form and/or additional pages.

2. 1.     List assignments and departments with time spent in each:
3. 2.     Summary of learning experiences:
4. 3.     Brief analysis of any problems observed, new experiences, insights gained:
5. 4.     Statement of any problems that arose during the training:

6. 5.     Visits outside the facility, educational conferences attended:

   I hereby certify that the information listed on this report form are true and correct to the best of my knowledge and belief.

   (Signature of AIT)

   The training that I have listed was supervised by:

   TO BE COMPLETED BY THE SUPERVISING LICENSED NURSING HOME ADMINISTRATOR:

   I certify that the AIT under my supervision has had the training listed and that this AIT

   received           hours of training and worked         days per week during this period.

   (Signature of Preceptor)

Author: Jacob L. Cureton, Jr.

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

History: Amended: January 16, 2001; effective February 20, 2001.