Titles of Regulations: 18VAC95-20. Regulations Governing the Practice of Nursing Home Administrators.

18VAC95-30. Regulations Governing the Practice of Assisted Living Facility Administrators.

Agency Contact: Corie Tillman Wolf, Executive Director, Board of Long-Term Care Administrators, 9960 Mayland Drive, Suite 300, Richmond, VA 23233-1463, telephone (804) 367-4546, or email [email protected].

FORMS (18VAC95-20)

Nursing Home Administrator Application General Information (rev. 9/08).

Nursing Home Administrator Application for Initial Licensure (rev. 3/10).

License Verification Form (rev. 3/10).

Nursing Home Administrator-in-Training Application (rev. 3/10).

Nursing Home Administrator-in-Training – Notice of Change of Status or Discontinuance (rev. 3/10).

Nursing Home Administrator Preceptor Application (rev. 3/10).

Nursing Home Administrator Application for Reinstatement of License (rev. 3/10).

Nursing Home Administrator Application for Licensure by Endorsement (rev. 3/10).

Nursing Home Administrator-in-Training Monthly Report (rev. 4/10).

Nursing Home Administrator-in-Training Documentation of Completion Form (rev. 3/10).

Domains of Practice (rev. 3/10).

Nursing Home Administrator Application - form available online only at https://www.license.dhp.virginia.gov/apply/

Nursing Home Administrator-in-Training Application, online form available at https://www.license.dhp.virginia.gov/apply/

Nursing Home Administrator-in-Training Notice of Change of Status or Discontinuance (rev. 3/2019)

Nursing Home Administrator Preceptor Application, online form available at https://www.license.dhp.virginia.gov/apply/

Checklist and Instructions for Nursing Home Administrator Reinstatement Application (rev. 3/2019)

Monthly Report of Nursing Home Administrator-in-Training (rev. 3/2019)

Nursing Home Administrator-in-Training Documentation of Completion Form (rev. 3/2019)

Proposed AIT Program Training Plan Domains of Practice (rev. 3/2019)

Continued Competency Activity and Assessment Form for Nursing Home Administrators (rev. 10/2014)

Continued Education (CE) Credit Form for Voluntary Practice (eff. 2/2018)

FORMS (18VAC95-30)

Checklist for Endorsement or Credentials Application to Practice as an Assisted Living Facility Administrator (rev. 3/10).

Checklist for Initial Licensure by Education to Practice as an Assisted Living Facility Administrator (rev. 3/10).

Assisted Living Facility Administrator Application for Licensure (rev. 3/10).

Assisted Living Facility Administrator Administrator-in-Training Application (rev. 4/10).

Monthly Report of Assisted Living Facility Administrator-in-Training (rev. 3/10).

Completion of Assisted Living Facility Administrator-in-Training (rev. 3/10).

Endorsement Certification Form (rev. 8/07).

Assisted Living Facility Administrator Preceptor Application (rev. 4/10).

Domains of Practice (rev. 11/09).

Assisted Living Facility Administrators Education and Experience Matrix (rev. 3/2019)

Assisted Living Facility Administrator Application for Licensure - form available online only at https://www.dhp.virginia.gov/nha/nha_forms.htm#alfa

Assisted Living Facility Administrator Administrator-in-Training Application - form available online only at https://www.dhp.virginia.gov/nha/nha_forms.htm%23alfa

Monthly Report of Assisted Living Facility Administrator-in-Training (rev. 3/2019)

Assisted Living Facility Administrator-in-Training Documentation of Completion Form (rev. 3/2019)

Assisted Living Facility Administrator-in-Training Notice of Change of Status or Discontinuance (rev. 3/2019)

Assisted Living Facility Administrator Preceptor Application - form only available online at https://www.dhp.virginia.gov/nha/nha_forms.htm#alfa

Proposed AIT Training Plan Domains of Practice (rev. 3/2019)

Checklist and Instructions for Assisted Living Facility Administrator Reinstatement Application (rev. 3/2019)

Checklist and Instructions for Assisted Living Facility Administrator Preceptor Reinstatement Application (rev. 3/2019)

Checklist and Instructions for Acting Assisted Living Facility Administrator-in-Training (rev. 3/2019)

Continuing Competency Activity and Assessment Form for Assisted Living Facility Administrators (rev. 9/2010)

Continuing Education (CE) Credit Form for Volunteer Practice (eff. 2/2018)

Name/Address Change Form (rev. 3/2019)

Request for Verification of Virginia NHA or ALFA License (eff. 3/2019)