Get Nursing Assistant Registry Update Form

Filling out the Nursing Assistant Registry Update Form online is a straightforward process that ensures your information is accurately recorded. This guide will help you navigate the form's sections efficiently, allowing for a seamless update of your registry details.

Follow the steps to complete your Nursing Assistant Registry Update Form online.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. In Section A, provide your applicant information. Start by entering your Social Security number, which also serves as your nursing assistant certificate number. Next, fill out your legal name in the format of Last, First, Middle. Ensure to provide your current mailing address, including any apartment or box number, followed by the city, state, and zip code. Remember to note that any name changes require supporting documents.
3. Continue in Section A by filling in your phone number, ensuring the area code is included. It is vital to note that the form cannot be processed if required changes to your Social Security number lack a photocopy of your Social Security card.
4. If applicable, indicate that you worked for a staffing agency; this requires Section B to be completed by the nursing facility where you worked. Make sure that this form should not be filled out by the staffing agency.
5. Section B is dedicated to your employment information and must be filled out by your employer. The employer should provide the name of the facility or home health agency, along with their contact phone number and address. They will also need to specify the department or area where you worked, your employment start date, and the actual last working date.
6. Request your employer to indicate if you worked through a staffing agency and to attach a job description if employed outside of a nursing home or certified home health agency. This is critical for verification purposes.
7. The administrator or director of nursing at the facility must complete the verification section where they confirm your employment status and dates. They will need to sign and date this section.
8. Finally, you, as the nursing assistant, need to sign the form, certifying that the information provided is true and correct. Make sure to include the date.
9. Once all sections are completed, ensure all necessary documents, like a recent pay stub and job description, are attached. You can then save changes, download, print, or share the form as needed.

Complete your Nursing Assistant Registry Update Form online today for a smooth updating experience.