Pam's Add A Learner Page - Woodfords Family Services

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*

Agency*

Date of Hire as BHP*

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:

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 No

Adult & Child CPR with AED Certified*

No
Yes

CPR Expiration Date

Adult & Child First Aid Certified:*

No
Yes

First Aid Expiration Date

OSHA compliant Blood Borne Pathogen Training:

No
Yes

Date of completion:

Program and Education Details

MaineCare 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 necessary

Degree Awarded*

Please enter "diploma" or "GED" for high school level employees.

Major*

Please enter "N/A" for high school level employees.

Authorization

Background 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 number

Including your phone number is not required, but it provides us with another way to contact you in the event of issues with your employees.

Pam’s Add A Learner Page

Add BHP Learner

BHP New Learner 2017

Education, Training and Employment Documentation

Additional Requirements for full BHP Certification:

Program and Education Details

Authorization

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