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Massachusetts Nurse Aide Registry Renewal Form - certified nurse aide renewal form


Massachusetts Nurse Aide Registry Renewal Form-certified nurse aide renewal form

AMERICAN RED CROSS TESTING OFFICE
85 Lowell Street, Peabody, MA 01960
1-800-962-4337/ 781-979-4010
www.redcross.org matesting@redcross.org
Massachusetts Nurse Aide Registry Renewal Form
Complete Sections I and II. Print or type all information.
This form must be signed and dated by the Employer to be valid.
SECTION I: NURSE AIDE INFORMATION
If changing social security number, please provide copies of both your old and new
social security cards. If your name has changed please provide legal documentation.
Name: Social Security:
Address: Date of Birth: ____________________________
Phone #:
Email:
Take this form to your current or former employer to complete Section II.
SECTION II: CURRENT OR MOST RECENT HEALTH CARE EMPLOYER
Name of Employer:
Address:
Facility Phone #:
Type of Employer (check one):
Long-term care facility VPN: (long-term care facility only)
Home health agency Private*
Staffing agency Hospice
Hospital, clinic Other
Must be completed and Date of hire: / / Date of termination: / /
must include month, MO/DAY/YEAR (if currently unemployed) MO/DAY/YEAR
day and year:
Eligibility for recertification: MUST BE COMPLETED IN ORDER TO BE PROCESSED:
The herein-named individual has worked for pay as a nurse aide, under the supervision of a nurse, for the health
care employer listed above for at least eight hours performing nursing related duties.
IMPORTANT: SEE PAGE TWO OF THIS FORM FOR A DESCRIPTION OF NURSING RELATED DUTIES.
I certify that the information put forth on this Massachusetts Nurse Aide Registry Renewal Form is true and
correct to the best of my knowledge.
Employer Signature: Date of Signature: / /
MO/DAY/YEAR
Employer Name (please print or type):
Email Address:
Title: Circle one: Present Former
Employer Employer
*If privately employed, please have your client's physician (including their office number) or nurse (including their license number)
sign this form and print their name with the requested information.
. ..
Signature Printed name Office Number or License Number
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If you do not meet the criteria below, you are not eligible to renew and must take the knowledge and clinical
skills test to remain active on the Massachusetts Nurse Aide Registry.
Injury prevention, safety and emergencies -Nutrition
-Body Mechanics -Assisting residents with meals
-Identifying potential hazards to residents -Fluids
-Knowledge of proper use of resident's equipment -Assisting with elimination
-Fire protection and burns -Position, transfer, and turning
-Falls, Seizures, Oxygen use -Caring for resident's environment and belongings
-Choking-Heimlich maneuver -Skin care
Prevention and control of infection Communication skills to promote a positive
-How microorganisms cause infections atmosphere
-Strategies for breaking the chain of infection -Basic human needs and principles of
transmission communication
-Standard Precautions -Confidentiality, ethics, and issues of resident rights
-Special equipment and supplies for infection -Call lights
prevention and control -Helping residents do more for themselves
-Symptoms of common infections -Communication with residents with visual or
-Isolation procedures hearing impairment
-Communicating with depressed residents
Resident's Rights -Communicating with residents with dementia
-Recognition of resident's rights, which are: -Communicating with friends and relatives
-Consequence of not assuring resident's rights -Responding to sexual advances or physical abuse
-Reporting violation of resident's rights -Responding to demanding residents
Basic nursing skills Restorative care
-Height and weight -Application of assistive devices
-Vital signs -Range of motion exercises
-Intake/Output -Walking with a resident
-Bed making -Bowel and bladder training
-Collecting specimens -Self care
-Application of support hose and elastic stocking -The aging process
-Hot and cold applications
-Nonprescription preparations Responding to typical resident behaviors
-Assisting with an ostomy -Anger
-Caring for the resident's environment -Combativeness
-Caring for the resident when death is imminent -Confusion
-Acute and chronic illness, disease, or problems -Delusions
-Observing and reporting potential health problems -Depression
-Hallucinations
Personal care skills -Hoarding
-Bathing -Suspiciousness
-Oral hygiene -Wandering
-Grooming
-Dressing and undressing
Please return the completed Renewal application as soon as possible. We will send your new certificate and a
wallet card to you within 30 days of our receipt of a completed Renewal application. Your NEW expiration
date will be determined by adding TWO years to your last known date of employment as a Nurse Aide.
Please send your completed form to:
American Red Cross Testing Office
Renewal Program
85 Lowell Street
Peabody, MA 01960
You must MAIL your original form to our office. Copied, emailed or faxed renewal forms will not be accepted.
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How to renew your certified nurse aid? You must renew you certification prior to the expiration date. ... You must prove that you have worked as a CNA during the last two years for the minimum number of hours set forth by your state's Nursing Aide Registry. ... You must take the certification exam again if you have not worked as a CNA in the past two years. More items...