To register concerns or complaints about Nurse Delegation, please call 1-800-562-6078

DISTRIBUTION:  Copy in client chart and in RND file

NURSE DELEGATION:  ASSUMPTION OF DELEGATION

DSHS 13-678B (REV. 09/2021)

Instructions for Completing Nurse Delegation:  Assumption of Delegation

All fields are required unless indicated “OPTIONAL”.

1. Client Name: Enter ND client’s name (last name, first name).
2. ACES ID: Enter client’s ACES Identification number.
3. Date of Birth: Enter ND client’s date of birth (month, day, year).
4. ID Setting: OPTIONAL – Enter client’s ID number as assigned by your business OR enter settings “AFH”, “ALF”,               DDA Program, “In-home”.
5. Facility or Program Name: OPTIONAL – Enter name of facility/program contact.
6. Telephone Number: OPTIONAL – Enter telephone number of facility/program contact including area code.
7. Reason/Dates for Another RND to Assume Delegation: Enter reason other RND rescinded and the date you assume        responsibility for delegation.
8. and 9. Assuming RND Signature and Date: Sign and date your signature.