DSS Form 2433 (3/23/26)

Adult Protective Services

PERSONAL CARE/CERTIFIED NURSING ASSISTANT TRAINING LOG

Name of Employee: Date of Hire:

Provider Business Name:

Employee’s Position (Director, Personal Care Assistant, etc.):

In accordance with DPH regulations for in-home care providers, Certified Nursing Assistants, Personal Care Assistants, and Homemakers must receive or independently obtain necessary training to perform the duties for which they are responsible prior to providing services independently.

Training Topic Trainer Date No. Hours

Basic first aid

Medication assistance

Care services for persons specific to the physical and/or mental condition of the individual (e.g., Alzheimer’s disease, related dementia, cognitive disabilities, or similar disabilities)

Confidentiality

Documentation and recordkeeping procedures

Ethics and interpersonal relationships

Proper lifting and transfer techniques

Infection control techniques

Note: Personal Care Assistants, Certified Nursing Assistants, and Homemakers must also have five

(5) hours of training annually on one or more of the DPH required training topics listed above.

This form must be kept in the employee’s file on-site and must be made available upon request during SCDSS monitoring visits.

DSS Form 2433 (3/23/26)

Instructions

1. Enter the name of the employee for whom you are tracking in the “Name of Employee” field

2. Enter the date that the employee was hired in the “Date of Hire” field

3. Enter the name of the Provider (Sitter) Service in the “Provide Business Name” field

4. Enter the employee’s title with the Provider (Sitter) Service in the “Employee’s Position” field

5. Enter the following information in the table:

a. For the Training Topics listed in the table, which are also listed in the contract:

i. Examples of each pre-filled training topic include:

• Basic first aid

• Medication assistance

• Depending on the type of clients, care services for persons specific to the physical and/or mental condition of the individual (e.g., Alzheimer’s disease, related dementia, cognitive disabilities, or similar disabilities)

• Confidentiality of client information and records and the protecting of client rights, including prevention of abuse and neglect

• Documentation and recordkeeping procedures, including training on procedures for completing DSS Form 30141: Personal Care/Certified Nursing Assistant Verification of Care

• Ethics and interpersonal relationships

• Proper lifting and transfer techniques

• Infection control techniques

ii. Name of the trainer (Note: If the training is presented electronically, please indicate that it is online or electronic training in this field.)

iii. Date the employee completed the training

iv. Number of hours the training covered