APPLICANT NAME: ______________________________________________ EMERGENCY SITUATION FORM TO BE COMPLETED BY THE APPOINTING AUTHORITY APPOINTING AUTHORITY INFORMATION Name, Title:

Direct Telephone Number: (

)

Fax Number: (

)

FACILITY INFORMATION Name of Nursing Home Facility OR Hospital for which temporary permit is required:

Street and Number:

Address:

City, State, Zip:

Telephone Number: (

) EMERGENCY SITUATION

Date the emergency situation occurred: Describe the emergency situation:

ADMINISTRATOR VACANCY When and where were advertisement(s) placed to fill this vacancy?

How long were these advertisement(s) published? ►

Submit copies of any advertisement(s) that have been published.

How many applicants have you had for this vacancy? List the reasons why these applicants did not qualify to fill this vacancy:

ATTESTATION OF APPOINTING AUTHORITY I hereby certify that this applicant is employed as the hospital administrator at the general hospital designated above and qualifies for a temporary license as a nursing home administrator in accordance with § 12-39-108(6), C.R.S. and Board Rules II.C.1 and 3.

Signature of Appointing Authority

Date

Printed Name

Title

Emergency Situation Form –Nursing Home Administrator Temporary Permit (NHATPE) and Temporary Permit Hospital Administrators (TNHAB)

APPLICANT NAME: ______________________________________________

Emergency Situation Form –Nursing Home Administrator Temporary Permit (NHATPE) and Temporary Permit Hospital Administrators (TNHAB)