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