Texas Department of Aging and Disability Services Form 5506-NAR September 2014-E Texas Nurse Aide Registry Employment Verification Section 1. To be completed by Nurse Aide Please read the following instructions before completing this form. ● Complete all information in Section 1 and sign to verify that the information provided is correct. ● Attach a legible photocopy of a picture identification that shows your birth date and the correct spelling of your name. ● Obtain employer verification (Section 2). Form must be mailed to: Texas Nurse Aide Registry, P.O. Box 149030, MC E-414, Austin, TX 78714-9030. Faxes and copies will not be processed. To verify your Certified Nurse Aide (CNA) number, please call 1-800-452-3934. Note: A list of approved in-service education programs can be found at: http://www.dads.state.tx.us/providers/nf/credentialing/nar/ education_programs.html. The Texas Nurse Aide Registry will return (without action) incomplete requests and requests without the required documents. Maiden Name (if applicable) Name of Applicant (Last, First, Middle) Mailing Address (Street or P.O. Box) City State Social Security No. Sex ZIP Code Daytime Area Code and Telephone No. Date of Birth (mm/dd/yyyy) Male Female CNA Certificate No. Verification of requirements for Nurse Aide Recertification Are you listed on the Employee Misconduct Registry (EMR) as unemployable?........................................................................ Yes No Have you been found to have a conviction of a criminal offense listed in Texas Health and Safety Code, §250.006? .............. Yes No Yes No If yes, give date of conviction. Have you completed 24 hours on in-service education in the past two years?........................................................................... If yes, list the name of the nursing facility or NATCEP where you completed the training. Date Signature – Nurse Aide Section 2. To be completed by the Employer Instructions: ● This section must be completed by the facility program director, official keeper of records or actual employer. ● Notarize employer signature at the bottom of this section and return to nurse aide. Employer Name or Company Name Vendor ID (if applicable) Mailing Address (Street or P.O. Box) Daytime Area Code and Telephone No. City State ZIP Code I certify that the individual named above is/was employed by me as a nurse aide and performed nursing/nursing-related services from (mm/dd/yyyy) to (mm/dd/yyyy) and that I am not aware of any disqualifying misconduct. Comments: Date Signature – Employer Sworn and subscribed to me on this in day of County, in the state of Place Notary Seal or Stamp Here , 20 , . Signature – Notary Public Date Commission Expires Tampering with or attempting to falsify a government record as such a nurse aide certificate is a third-degree felony punishable by up to 10 years in prison and a $10,000 fine. Form 5506-NAR Page 2 / 09-2014-E Address: ● Did you enclose a legible photocopy of your picture ID? ● Did you sign Section 1? ● Did your employer notarize his/her signature in Section 2? Did you know? ● You can verify certificate status by calling 1-800-452-3934. ● You can download forms from our website: http://www.dads.state.tx.us/providers/nf/credentialing/nar/forms.html Texas Nurse Aide Registry Mail Code E-414 P.O. Box 149030 Austin, Texas 78714-9030 [email protected] With a few exceptions, you have the right to request and be informed about the information that the Department of Aging and Disability Services (DADS) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask DADS to correct information that is determined to be incorrect (Government Code, Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, please contact the Nurse Aide Registry at 512-438-2050.
© Copyright 2019 ExploreDoc