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NURSE AIDE I REGISTRY RECIPROCITY APPLICATION - nevada nurse aide registry reciprocity


NURSE AIDE I REGISTRY RECIPROCITY APPLICATION-nevada nurse aide registry reciprocity

North Carolina Department of Health and Human Services
Division of Health Service Regulation
Health Care Personnel Education and Credentialing Section
Phone: 919-855-3969
NURSE AIDE I REGISTRY RECIPROCITY APPLICATION
DHSR Has 10 Business Days from Date of Receipt to Review the Application.
INSTRUCTIONS:
Review Part 1 below and determine if you meet the eligibility requirements to be listed on the North Carolina Nurse
Aide I Registry.
If you meet the eligibility requirements, then complete and submit all pages of the application (pages 1 through 6)
and any required supportive documentation. Incomplete applications will not be processed.
Please use black or blue ink only. Other ink colors are not be readable via fax.
Return completed application by mail or fax.
o Mailing Address: 2709 Mail Service Center, Raleigh, NC 27699-2709
o Fax Number: 919-733-9764
Do Not Submit More Than One (1) Application Unless Instructed by DHSR.
PART 1: DETERMINE ELIGIBILITY
Consistent with Rule 10A NCAC 13O .0301, to be eligible to be listed on the North Carolina Nurse Aide I Registry, you
must meet the five (5) criteria listed below.
1. You are listed as active and in good standing on another State registry of nurse aides.
o A temporary listing on a State registry of nurse aides will not be accepted.
2. You have no pending or substantiated findings of abuse, neglect, exploitation, or misappropriation of resident or
patient property recorded on any State registry of nurse aides.
3. You have been employed as a nurse aide for monetary compensation consisting of at least a total of eight hours of
time worked performing nursing or nursing-related tasks delegated and supervised by a Registered Nurse in the past
two years (previous 24 consecutive months).
o If you have not been employed as a nurse aide, then you are only eligible for reciprocity if you successfully
passed a state-approved nurse aide I competency examination and was listed on the Nurse Aide I Registry in
the State(s) of reciprocity in the past two years (previous 24 consecutive months).
o Private duty nurse aide employment type does not meet the eligibility requirements for reciprocity.
4. You have a social security card and an unexpired government-issued identification containing a photograph and
signature.
o The name listed on your social security card and unexpired government-issued identification containing a
photograph and signature must match.
o The name listed on both identifications must match the name listed on the nurse aide registry in the State(s)
of reciprocity.
o If the names do not match, then you must submit documentation verifying any name changes (e.g., birth
certificate, marriage license, divorce decree, notice of resumption of former name, etc.).
5. You completed a state-approved nurse aide training and competency evaluation program that meets the requirements
of 42 CFR 483.152 or a state-approved competency evaluation program that meets the requirements of 42 CFR
483.154.
DHSR/HCPEC-4515 (Revised October 2020) Page 1 of 6
PART 2: PERSONAL INFORMATION
Answer all questions.
Print legibly.
Include hyphens and suffixes in your legal name if applicable (No Nicknames).
First Name: Middle Name: Last Name:
Prior Name(s) (if applicable):
First Name: Middle Name: Last Name:
First Name: Middle Name: Last Name:
Gender: Social Security Number: Email Address:
(include all 9 numbers)
Male Female
Telephone Number: Date of Birth: Mother's Maiden Last Name:
(include area code)
_________/________/__________
mm dd yyyy
Did You Serve in the Military? Are You Currently Married to an Active
Member of the Military or a Military Veteran?
Yes No Yes No
Did You Work in a Military Occupational Specialty (MOS)
Where You Performed Nursing or Nursing-Related Tasks?
Yes No I Did Not Serve in the Military
Mailing Address:
Street/PO Box: Apt. #:
City: State:
Zip Code: County:
DHSR/HCPEC-4515 (Revised October 2020) Page 2 of 6
PART 3: STATE-APPROVED NURSE AIDE I TRAINING & COMPETENCY EVALUATION PROGRAM
Answer both questions below.
YES NO Did You Complete a State-Approved Nurse Aide I Training Program that Consisted of At Least
75 Hours of Training?
YES NO Did You Successfully Pass a State-Approved Nurse Aide I Competency Examination?
PART 4: NURSE AIDE I REGISTRIES
Complete the table and questions below.
List all states that you have an active or expired nurse aide I registry listing. We will verify that you have no
findings in the states where your listing is active or expired.
For all active listings, you must include, with this application, documentation verifying that each registry
listing is active and in good standing in the State of reciprocity. The documentation should be dated within
30 calendar days before the date your application is received by the Department.
If your listing is active in the state of Alabama, then you must submit a signed letter from your current or
former employer, on official company letterhead, indicating your nurse aide status is active in the state of
Alabama.
State Name or Is Your Registry Original Issue Date: Expiration Date: Registry Certification or
Abbreviation: Listing Registration Number:
Current/Active?
YES NO
______/______/______ ______/______/______
mm dd yyyy mm dd yyyy
State Name or Is Your Registry Original Issue Date: Expiration Date: Registry Certification or
Abbreviation: Listing Registration Number:
Current/Active?
YES NO
______/______/______ ______/______/______
mm dd yyyy mm dd yyyy
State Name or Is Your Registry Original Issue Date: Expiration Date: Registry Certification or
Abbreviation: Listing Registration Number:
Current/Active?
YES NO
______/______/______ ______/______/______
mm dd yyyy mm dd yyyy
YES NO Are You Listed on More Than Three State Nurse Aide Registries in an Active or Expired
Status?
If you answered YES, then you must attach a separate sheet of paper providing the registry information for the
States not listed in the table above.
DHSR/HCPEC-4515 (Revised October 2020) Page 3 of 6

What is a Nevada reciprocity applicant? DEFINITION: A reciprocity applicant is an individual who has current certification from National Registry or State of Nevada.