State of Illinois
Illinois Department of Public Health
HHA Agency Supervisor Qualification Review Form
Form Number (445104) Page 1 of 3
HOME HEALTH AGENCY ONLY
Attachment B - Agency Supervisor Qualification Review Form
Section 245.30 of the 77 Illinois Administrative Code requires this position to be filled by an individual who is a registered nurse who has
completed a baccalaureate degree in Science of Nursing (BSN) program and has at least one year of nursing experience as a BSN; or a
registered nurse without a baccalaureate degree, who has at least three years of nursing experience as an Registered Nurse within the last
five years (two of those years in a home health agency, a community health program caring for the sick, or a family centered nursing program
in a community health agency). Section 245.20 defines a registered nurse as a person currently licensed as an Registered Nurse under the
Illinois Nursing Act.
Agency Name
License Number
Address
City
State
ZIP Code
Agency Supervisor Information
Last Name First Name
Middle Initial
Address
City
State
ZIP Code
Daytime Phone number (include area code and extension)
Section 245.30 requires that the agency supervisor must be a Registered Nurse.
Indicate the highest educational level obtained:
ADN Diploma R.N. B.S.N. B.A. B.S. Master's Doctorate
Please list the college(s) attended, the address, date of graduation, specialty and degree obtained.
Name of College
Address of College
City
State
ZIP Code
Date of Graduation Specialty/Degree
Name of College
Address of College
City
State
ZIP Code
Date of Graduation Specialty/Degree
Please list the high school attended, the address, and date of graduation.
Name of High School Date of Graduation
Address of High School
City
State
ZIP Code
State of Illinois
Illinois Department of Public Health
HHA Agency Supervisor Qualification Review Form
Form Number (445104) Page 2 of 3
List applicable professional licenses, registrations and/or certifications currently held with the license number, date
of expiration and state that issued the license, registration or certification. ATTACH A COPY OF YOUR
CURRENT ILLINOIS LICENSE. YOUR CURRENT EMPLOYER MUST BE THE AGENCY IDENTIFIED IN THIS
APPLICATION. Please include a letter of intentions with this application (the agency supervisor is
required to be full time upon licensure. Provide documentation that the applicant is resigning present
employment upon licensure, or if working part time elsewhere, the applicant's other employment is
outside the agency's hours of operation).
Describe your relevant work experience for the last five years.
(1) List your most recent position with THIS AGENCY FIRST and work backward.
(2) Give the starting and ending dates (month and year) for each employment and the weekly hours worked.
(3) Describe the administrative functions performed for each position, with each agency, that qualify you to function as the
agency supervisor of a home health agency.
(4) Include the names, addresses and telephone numbers of organizations.
You may use an additional sheet of paper to complete this section. Resumes are not accepted in lieu of completion of this
portion of the form.
Current Employer Name
Address of Current Employer
City
State
ZIP Code
Starting (month and year)
Ending (month and year) Total Hours Worked Weekly
Duties
Previous Employer Name
Address of Previous Employer
City
State
ZIP Code
Starting (month and year)
Ending (month and year) Total Hours Worked Weekly
Duties
Attachment B-Agency Supervisor Qualification Review Form Page 2
Update 2022
State of Illinois
Illinois Department of Public Health
HHA Agency Supervisor Qualification Review Form
Form Number (445104) Page 3 of 3
Previous Employer Name
Address of Previous Employer
City
State
ZIP Code
Starting (month and year)
Ending (month and year) Total Hours Worked Weekly
Duties
Have you ever been convicted of a criminal offense?
Yes No
Are there any pending or administratively resolved issues concerning your professional license in Illinois or in
another state?
Yes No
If you answered “yes” to either or both of the above statements, please describe the criminal offense and/or the
pending or administratively resolved licensure issues in detail, including the state of administrative action
[Section 245.130 b) 2]. You may attach an additional sheet of paper if necessary for the explanation.
I signify that the information contained in this form is true and correct to the best of my knowledge and belief. I
realize that misrepresentation of this information at any time may be cause for denial of this application, or future
revocation of a license.
Signature of Applicant (Original Only) Date
Attachment B - Agency Supervisor Qualification Review Form Page 3
Update 2022
