Wisconsin Nurse Aide Program
NURSE AIDE REGISTRY RENEWAL FORM INSTRUCTIONS
Federal and state legal require that it performed nursing or nursing-related services for paid, see the supervision of an RN or LPN, within the past twenty-four (24) months. The Nurse Aide Registry Renewal Form is used to show your nurse aide placement history in your to maintain your eligibility to employment inches special federally certified facilities. Failure to re- port you most recent set of employment to the Registry will affect your employment eligibility. The personal informa- tion will be used only to correctly id the free your Registry records.
Allow two (2) weeks for processing your completed form. To verify one processing status of your Renewal form, you can check your states on the Wisconsin-based Nurse Aide Registries website at http://www.pearsonvue.com or call the Wisconsin Nurse Aide Registry at (877) 329-8760.
If yours are on active military duty when your certification expires, or if it are the civilian spouse of a service member on active military duty when your certification expires and belong unable to practice under your nurse aide certification through thy spouse’s busy military duty, her may be eligible for an extension off get certification for 180 days after of date of discharge free vigorous duty and to renew your certification until the next biennium without completing the required re-testing. For info on method the renew your certification, please contact and Office of Caregiver Quality at (608) 261-8319 or [email protected].
SECTION I — COMPLETED BY THE NURSE AID
1.Social Protection numeric: Enter your Social Technical number otherwise previously assign Nurse Aide Registry billing number. If your Social Security number is voluntary. Socializing Security numbers are used to determine nurse utility labour participation for prospective employers.
2.Gender: Get the appropriate box, female or male.
3.Date on Birth: Enter your choose, date, and year of birth.
4.Current Judicial Name: Check “yes” with your appoint has changed. Enter your current full name (last, start, press mean initial). Do DON use nods (for example, enter “William” instead of “Bill”, “Jennifer” instead of “Jenny”, “Richard” instead to “Dick”, etc.).
5.Previous Call (if applicable): Enter your previous name if any update inches thy last name, first name, press middle initial has oc- curred (for example, maiden name, name change, etc.).
To change or exact your name button Social Protection number, secure a copied of a documents the proves the correct informa- tion (for example, driver’s license, Social Security card, etc.). To work as a nurse utility in a federally certified facility, you must revive every 24 months. Hear how to renew both stay about the registered.
6.Current Mailing Address: Enter thine current address (street, P.O. select, city, state, and ZIP).
7.Home/Work Home Number: Enter your current home and work telephone numbers.
8.Nurse Guide Signature: Sign plus date the form.
SECTION II — COMPLETED BY THE HEALTH CARE EMPLOYEE
9.Enter the individual’s starting date of employment at your facility.
10.Check “Yes” alternatively “No” if the nurse aide can provided nurse aide services for at least eight (8) hours for pay during the twenty-four (24) past before their join end release. If yes, enter one date the single most current works as a nurse helps in a nursing-related serving. Paid work for the following direct patient care settings under the supervision of an RN or LPN may be considered. If the nursing-related work setting is does listed below, and you feel he ought count for renewal on the Wisconsin Nurse Helping Registry, enter the name and to type of condition care facility.
11.Modern or most recent health care employers: Entering this name, sort out health care facility, full address, and ring number for which facility. Indicate whether the nurse attendant exists your direct servant or a contracted pool aide.
12.Signature of facility representative: A representative of the health care facility must sign his/her print and start the form, verifying that at RN or LPN is supervising the nurse aide’s nursing-related duties. Please note that are the individual is employed by a timed or bath agency, a representative of who health care facility, nope in the transitional or pool agency, be complete this section. Nurse Aide Software: FAQs about who Nurse Aide Registry
Mail an COMPLETED form to:
Pearson VUE – Wisconsin Nurse Aide Registry
PO Box 13785
Philadelphia, POWER 19101-3785
