DSD APPROVAL PACKET: A HOW TO

Charlotte F. Hopkins MBA, BSHA, LVN, DSD, IP

Owner of Creative Medical Education and Training Solutions (CMETS)

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CDPH FORMS

• 279
• 278A
• 278B
• 278R
• 193

Application Packet

• You must submit all forms.
• The packet should be scanned and emailed to: TPRU@cdph.ca.gov
• Make sure to keep a hard and digital copy of all documents
• 🖮 Go to CDPH’s website to print the latest document: https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/TPRU-Forms-for-All-Program-Types.aspx

CDPH 279 – Director of Staff Development Application

Include:

• Resume with employer name, address, phone number, supervisor name, and dates of employment. Be sure to write the words, “provided direct patient care”
• DSD training certificate
• A State Approval number on a CDPH form if applicable

CDPH 278A -Orientation Program

Submit:

• One lesson plan for a patient care skill used during the supervised clinical training
• Copy of the orientation/yearly skills checklist

Page 1

CDPH 278A -Orientation Program

Submit:

• One lesson plan for a patient care skill used during the supervised clinical training
• Copy of the orientation/yearly skills checklist

Page 2

CDPH 278B�In-service Program

Submit:

• Two lesson plans for topics on this form
• 3 month in-service calendar
• In-service sign-in sheet
• Record keeping policy

Page 1

CDPH 278B�In-service Program

Submit:

• Two lesson plans for topics on this form
• 3 month in-service calendar
• In-service sign-in sheet
• Record keeping policy

Page 2

CDPH 278R�Combined Orientation, In-service, and NATP Renewal

• This form is used for both the initial and renewal submission and every two years thereafter.
• Changes in management requires this form to be fully completed.
• Example: section 1 & 2

Page 1

CDPH 278R�Combined Orientation, In-service, and NATP Renewal

• This form is used for both the initial and renewal submission and every two years thereafter.
• Changes in management requires this form to be fully completed.
• Example: section 1 & 2

Page 2

CDPH 278R�Combined Orientation, In-service, and NATP Renewal

• This form is used for both the initial and renewal submission and every two years thereafter.
• Changes in management requires this form to be fully completed.
• Example: section 1 & 2

Page 3

CDPH 278R�Combined Orientation, In-service, and NATP Renewal

• This form is used for both the initial and renewal submission and every two years thereafter.
• Changes in management requires this form to be fully completed.
• Example: section 1 & 2

Page 4

CDPH 193�Contact Information Form

• Must be submitted every time

Thank you