DHs-5121-ENg 6-07

Not Public
Adult Day Program
Center Director Personnel Requirements

You are asked to supply the data on this form so that the Minnesota Department of Human Services
may evaluate your request for licensure under Minnesota Rules, parts 9555.9600 to 9555.9730 (Rule
223) and Minnesota Statutes, Chapter 245A (Human Services Licensing Act).
NAME OF CENTER DIRECTOR: DATE OF EMplOyMENT:

NAME OF pROgRAM: pROgRAM lICENsE NuMbER:

ADDREss OF pROgRAM:

Minnesota Rules, part 9555.9680, subpart 1 Personnel Requirements for Center Director
The center director must meet both the requirements in items A and B or only the requirement in item C:
A. Licensure by the state of Minnesota as a licensed practical nurse or completion of at least two
years of postsecondary education from an accredited college, university, technical college or
correspondence school; and
B. Completion of two years of paid or volunteer experience in planning or delivering health or social
services including experience in supervision and administration; or
C. Completion of four years of paid or volunteer experience in planning or delivering health or
social services including two years of experience in supervision and administration.
Provide documentation to verify how you meet the personnel requirements as identified above. A copy of this
form and supporting documentation should also be placed in the personnel file to be maintained on site.
A. Attach to this form, a legible copy of your license as a licensed practical nurse or legible copies of
documents from the postsecondary training institutions, such as transcripts, diplomas, grade cards,
etc.; and
B. In the space below, document past work or volunteer experience in planning or delivering health or
social services including experience in supervision and administration; or
C. In the space below, document past work or volunteer experience in planning or delivering health or
social services including two years of experience in supervision and administration.

Address of place of
place of employment or Dates of employment or Name of supervisor
employment or volunteer
volunteer experience volunteer experience
experience

Licensors initials: Date:

Katie Adult Day Center Policies and Procedures Manual 02-004.16

A Product of LeadingAge Minnesota October 2016
 This document reprinted from https://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-5121-ENG

Katie Adult Day Center Policies and Procedures Manual 02-004.16

A Product of LeadingAge Minnesota October 2016