Pam’s Add A Learner Page Add BHP Learner BHP New Learner 2017 Education, Training and Employment Documentation This form must be completed by a Certified BHP Trainer or an agency's assigned representative. Fields marked with an asterisk (*) are required. All such fields must be completed in order to submit the form.Employee Name* First Last Last 4 SSN* Please enter only the last four digits of the employee's social security number.Employee Email* Enter Email Confirm Email Employee Phone*Please include the best number at which the employee can be reached, for example to be notified of changes to trainings during non-work hours. A personal cell phone number is preferable, whereas an office phone number is not recommended.Date of Birth* MM slash DD slash YYYY Agency* Date of Hire as BHP* MM slash DD slash YYYY Agency Location Enter a location if multiple locations exist for your agency.Registration for: (choose 1)* Module 1 online ONLY BHP (35 hour) Blended Learning Curriculum, Modules 1 - 12 online with Live Day Modules 2 - 12 online with Live Day (Employee has Provisional BHP Certificate) Effective Date of Provisional BHP Certificate: MM slash DD slash YYYY Additional Requirements for full BHP Certification:If the requirement is met, click Yes and enter the applicable date; if not or if the information is not available at this time, click NoAdult & Child CPR with AED Certified* No Yes CPR Expiration Date MM slash DD slash YYYY Adult & Child First Aid Certified:* No Yes First Aid Expiration Date MM slash DD slash YYYY OSHA compliant Blood Borne Pathogen Training: No Yes Date of completion: MM slash DD slash YYYY Program and Education DetailsMaineCare Program:* MC Section 28 RCS or RCS Specialized MC Section 28 School-Based MC Section 65 DT MC Section 65 HCT Education Level* High School Diploma or GED 60 higher education credit hours 90 college credits/CEUs School Name* Graduation Year* only year is necessaryDegree Awarded* Please enter "diploma" or "GED" for high school level employees.Major* Please enter "N/A" for high school level employees.AuthorizationBackground Check*By checking this box, I signify that my organization has conducted the required background checks for this individual in accordance with 22 MRS §9054 and has accessed the Maine Registry of Certified Nursing Assistants and Direct Care Workers (“the Registry”) in accordance with 22 MRS § 1812-G (2-A) to ensure this individual is not annotated. Background Check Completed Authorization*By checking this box, I signify that all of the information provided above is correct, has been authenticated by my Human Resources Department, and is on file at my Agency Authorized Agency Contact Name* First Last Contact Email Address* Enter Email Confirm Email A copy of the form data will be emailed to this address for confirmation of entry.Title/Position* Phone numberIncluding your phone number is not required, but it provides us with another way to contact you in the event of issues with your employees.