2024-2025 Child Health Training Program Application

North Carolina Department of Health and Human Services

Application for Child Health Enhanced Role Registered Nurse Training Program

Instructions:

Please complete the information below in order to apply to participate in the the Child Health Training Program.

Thank you

1. Name: *This question is required.

2. Agency Name: *This question is required.

3. Health Department Address (line 1): *This question is required.

4. Health Department Address (line 2): *This question is required.

5. Education resources will be mailed directly to the student. Please provide your home mailing address.
Home Mailing Address (line 1) *This question is required.

6. Home Mailing Address (line 2) *This question is required.

7. Email Address: *This question is required. This question requires a valid email address.

8. Phone Number - Direct work number (with extension if applicable) *This question is required.

9. Cell Phone Number *This question is required.

11. Please document dates (from/to) for each of the specialty areas with which you have past of present experience (choose all that apply): *This question is required.

	Generalized
	School Health
	Child Health
	Other (specify)

12. Indicate your nursing education date issued month/year (choose all that apply): *This question is required.

Diploma
Associates Degree
Baccalaureate Degree
Master's Degree
Doctorate Degree
Other (please specify)

13. Please indicate the date completed or the expected date of completion for the North Carolina Credentialed Public Health Nursing Course *This question is required.

Scan a copy of your certificate and email to CHTP@dhhs.nc.gov

If you do not have a copy of your certificate, the Office of Chief Public Health Nurse at the N.C. Division of Public Health, office number 919-707-5130, maintains course rosters.

14. Preceptor Qualifications: The primary preceptor must be an advanced practice provider or physician. It is strongly recommended that the provider have a specialty of Pediatrics or Family Medicine. Secondary preceptor(s), if applicable, may be a rostered CHERRN with a minimum of 2 years clinical practice. See the 2024-2025 CHTP Local Planning Document for more details. *This question is required.

Nurse Practioner
Physician Assistant
Physician
CHERRN (secondary preceptor only)

15. Provide the following information on the primary preceptor and secondary preceptor (if applicable): *This question is required.

Space Cell	Primary preceptor	Secondary preceptor (if applicable)
Name	Name: Primary preceptor	Name: Secondary preceptor (if applicable)
Health Department Address	Health Department Address: Primary preceptor	Health Department Address: Secondary preceptor (if applicable)
Home Address (Resources will be mailed directly to the preceptor. Please provide your home mailing address.)	Home Address (Resources will be mailed directly to the preceptor. Please provide your home mailing address.): Primary preceptor	Home Address (Resources will be mailed directly to the preceptor. Please provide your home mailing address.): Secondary preceptor (if applicable)
Phone	Phone: Primary preceptor	Phone: Secondary preceptor (if applicable)
Email Address	Email Address: Primary preceptor	Email Address: Secondary preceptor (if applicable)

16. Provide the following information on the Nursing Director and Clinical Supervisor: *This question is required.

Space Cell	Nursing Director	Clinical Supervisor
Name	Name: Nursing Director	Name: Clinical Supervisor
Address	Address: Nursing Director	Address: Clinical Supervisor
Office Phone	Office Phone: Nursing Director	Office Phone: Clinical Supervisor
Cell Phone	Cell Phone: Nursing Director	Cell Phone: Clinical Supervisor
Email Address	Email Address: Nursing Director	Email Address: Clinical Supervisor

17. Provide the following information regarding the physician who will provide standing orders (if applicable): *This question is required.

Space Cell	Medical Director who receives/approves nursing standing orders and provides ongoing consultation
Name	Name: Medical Director who receives/approves nursing standing orders and provides ongoing consultation
Address	Address: Medical Director who receives/approves nursing standing orders and provides ongoing consultation
Office Phone	Office Phone: Medical Director who receives/approves nursing standing orders and provides ongoing consultation
Email Address	Email Address: Medical Director who receives/approves nursing standing orders and provides ongoing consultation