Document 2483053

Wisconsin Nurse Aide Program
NURSE AIDE REGISTRY RENEWAL FORM INSTRUCTIONS
Federal and state regulations require that you performed nursing or nursing-related services for pay, under the supervision
of an RN or LPN, in the past twenty-four (24) months. The Nurse Aide Registry Renewal Form is used to report your nurse
aide employment history in order to maintain your eligibility to work in certain federally certified facilities. Failure to report your most recent date of employment to the Registry will affect your employment eligibility. The personal information will be used only to correctly identify and update your Registry records.
Allow two (2) weeks for processing your completed form. To verify the processing status of your Renewal form, you may check your
status on the Wisconsin Nurse Aide Registry website at http://www.pearsonvue.com or call the Wisconsin Nurse Aide Registry at
(877) 329-8760.
If you are on active military duty when your certification expires, or if you are the civilian spouse of a service member on active
military duty when your certification expires and are unable to practice under your nurse aide certification during your spouse’s
active military duty, you may be eligible for an extension of your certification for 180 days after the date of discharge from active
duty and to renew your certification to the next biennium without completing the required re-testing. For information on how to
renew your certification, please contact the Office of Caregiver Quality at (608) 261-8319 or [email protected].
SECTION I — COMPLETED BY THE NURSE AIDE
1. Social Security number: Enter your Social Security number or previously assigned Nurse Aide Registry identification
number. Providing your Social Security number is voluntary. Social Security numbers are used to determine nurse aide
employment eligibility for prospective employers.
2. Gender: Check the appropriate box, female or male.
3. Date of Birth: Enter your month, date, and year of birth.
4. Current Legal Name: Check “yes” if your name has changed. Enter your current full name (last, first, and middle initial). Do NOT
use nicknames (for example, enter “William” instead of “Bill”, “Jennifer” instead of “Jenny”, “Richard” instead of “Dick”, etc.).
5. Previous Name (if applicable): Enter your previous name if any change in your last name, first name, or middle initial has occurred (for example, maiden name, name change, etc.).
To change or correct your name or Social Security number, attach a copy of a document that proves the correct information (for example, driver’s license, Social Security card, etc.).
6. Current Mailing Address: Enter your current address (street, P.O. box, city, state, and ZIP).
7. Home/Work Telephone Number: Enter your current home and work telephone numbers.
8. Nurse Aide Signature: Sign and date the form.
SECTION II — COMPLETED BY THE HEALTH CARE EMPLOYER
9. Enter the individual’s starting date of employment at your facility.
10. Check “Yes” or “No” if the nurse aide has provided nurse aide services for at least eight (8) hours for pay during the
twenty-four (24) months before their registration expiration date. If yes, enter the date the individual most recently
worked as a nurse aide in a nursing-related service. Paid work in the following direct patient care settings under the
supervision of an RN or LPN may be considered. If the nursing-related work setting is not listed below, and you feel it
should count for renewal on the Wisconsin Nurse Aide Registry, enter the name and the type of health care facility.
01:
02:
03:
04:
Clinics
Community-Based
Residential Facilities (CBRFs)
Emergency Centers
Home Health Agencies
05:
06:
07:
Hospices
08:
Hospitals
09:
Intermediate Care Facilities for
Persons with Mental Retardation
(ICFs/MR)
Nursing Homes
County or School Nurse
11. Current or most recent health care employer: Enter the name, type of health care facility, full address, and telephone
number of the facility. Indicate whether the nurse aide is your direct employee or a contracted pool aide.
12. Signature of facility representative: A representative of the health care facility must sign his/her name and date the
form, verifying that an RN or LPN is supervising the nurse aide’s nursing-related duties. Please note that if the
individual is employed by a temporary or pool agency, a representative of the health care facility, not of the temporary or pool agency, must
complete this section.
Mail the COMPLETED form to:
Pearson VUE – Wisconsin Nurse Aide Registry
PO Box 13785
Philadelphia, PA 19101-3785
Incomplete, unsigned, or illegible forms will not be processed. If you have any questions about completing the Nurse
Aide Registry Renewal Form, please contact the Registry at (877) 329-8760.
Wisconsin Nurse Aide Program
NURSE AIDE REGISTRY RENEWAL FORM
Before completing this form, please carefully read the instructions on the reverse side.
If you are on active military duty when your certification expires or are the civilian spouse of a service member on active
military duty when your certification expires, do not complete this form. Instead please contact the Office of Caregiver
Quality at (608) 261-8319 or [email protected] to renew your nurse aide certification.
I II - I I - II II
SECTION I – COMPLETED BY NURSE AIDE (Please type or print neatly in black ink)
1. Social Security Number:
2. Gender:
I Female
3. Date of Birth Date:
I Male
I I - II - I I II
MONTH
DAY
To change or correct your name or Social Security
number, attach a copy of a document that proves
the correct information (for example, driver’s license,
Social Security card, etc.).
YEAR
4. Name Change?
I Yes
I No
CURRENT Full Name: DO NOT USE NICKNAMES
I II II II II II II II II II I II II II II II II II I
I II II II II II II II II II I II II II II II II II I
LAST
FIRST
MI
5. PREVIOUS Name (if applicable):
I II II II II II II II II II II II I II II I I II II I
I II II II II II II II II II II II II I I I I II II
I II - I II - I II I
I II - I II - I II I
FIRST
LAST
MI
6. CURRENT Mailing Address:
STREET (number and name)
APARTMENT NUMBER
CITY
PO BOX
STATE
7. Home Phone Number:
ZIP CODE
Work Phone Number:
AREA CODE
AREA CODE
8. Signature – Nurse Aide:
I
SIGNATURE OF APPLICANT
DATE SIGNED
CHECK HERE IF YOU DO NOT WISH TO DISCLOSE YOUR NAME AND ADDRESS ON LISTS THAT ARE FURNISHED BY PEARSON VUE UPON REQUEST.
I I - II - I II I
SECTION II – COMPLETED BY CURRENT OR MOST RECENT HEALTH CARE EMPLOYER
9. Enter the nurse aide’s START DATE at your facility:
MONTH
DAY
YEAR
10. Has the nurse aide provided nurse aide services for at least eight (8) hours for pay during the twenty-four (24) months
I Yes
I No
before their registration expiration date?
Enter the MOST RECENT DATE the person worked as an aide
providing a nursing-related service:
I I II I II I
I II II II II II II II II II II II II II I
II
II I - II I - II I I
MONTH
11. Name of Health Care Facility
Type of Health Care Facility (enter two-digit code):
DAY
YEAR
Phone Number
I Yes I No
I Yes I No
Staffing or Pool Aide?
Direct Employee?
12. Signature – Health Care Facility Representative:
I verify that the above-named individual has worked under the supervision of an RN or LPN.
SIGNATURE OF HEALTH CARE FACILITY REPRESENTATIVE
PRINTED NAME
DATE SIGNED
TITLE
This form may not be processed if the form is received by fax, or is incomplete, unsigned, or illegible.
PLEASE PRINT NEATLY IN BLACK INK. Then SIGN the form and MAIL it to:
Pearson VUE – Wisconsin Nurse Aide Registry, PO Box 13785, Philadelphia, PA 19101-3785
Copyright © 2012 Pearson Education, Inc., or its affiliate(s). All Rights Reserved. [email protected]
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