Get Interstate Endorsement Form

Completing the interstate endorsement form is essential for nurse aides seeking placement on the Nebraska Nurse Aide Registry. This guide will provide clear, step-by-step instructions to help you accurately fill out the form online.

Follow the steps to complete your form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your name in the designated fields. Provide your last name, first name, maiden name, middle name, and any other previously-used last names.
3. Fill in your mailing address, making sure to include the street address or P.O. box number, city, apartment number (if applicable), state, and zip code.
4. Next, enter your telephone number in the provided field for easy contact.
5. Input your Social Security number, which is required for processing your application.
6. Input your date of birth in the specified format and your place of birth, including the city and state.
7. Specify the name of the initial nurse aide training course you completed, along with the facility or college where you took the course, the total number of course hours, and the city/state of the course.
8. Fill in the course completion date accurately.
9. Provide the date you were approved and the state from which you were originally approved.
10. Enter your registration or certification number if applicable.
11. List all other states in which you are approved or have worked as a nurse aide, along with the corresponding dates approved or worked.
12. Indicate whether you have been employed as a nursing assistant during the past 24 months by selecting 'Yes' or 'No.' If 'Yes,' provide your registration or certification number.
13. List your nurse aide employers from the past 24 months, including their name, address, phone number, and dates worked.
14. Authorize the Department of Health & Human Services to request your nurse aide registry status from the identified states and employers by checking the appropriate box. Add your signature and the date signed.
15. Finally, return this form to the specified address or via email as required. Ensure that all sections are complete before submitting.

Complete your interstate endorsement form online today to ensure your placement on the Nebraska Nurse Aide Registry.