Get Private Duty Employment Verification Form - Prometric - Ct

The Private Duty Employment Verification Form – Prometric – Ct is an essential document for verifying a nurse aide’s employment in Connecticut. This guide will provide step-by-step instructions to assist you in completing the form accurately and efficiently online.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to obtain the Private Duty Employment Verification Form and open it in your online editing tool.
2. Fill in your name in the designated field at the top of the form.
3. Provide your current address, including city, state, and zip code in the appropriate sections.
4. Enter your telephone number in the specified field.
5. Input your Connecticut Nurse Aide Registration Number.
6. Enter your Social Security Number.
7. Indicate whether you are certified in any other states as a nurse aide. If yes, list those states in the provided area.
8. Switch to the employer section. The employer should fill in their name and full address.
9. Date of hire must be entered accurately, along with the last reported date of employment. If you are currently employed, use today’s date.
10. Provide a detailed description of the specific nursing or nursing-related activities performed. If additional space is needed, attach an extra sheet.
11. The employer representative should sign and date the form in the designated section, along with their telephone number.
12. Once all sections are completed, save the changes made to the form.
13. Download or print the completed form for submission.
14. Ensure that the form is sent directly from the employer to the CT Nurse Aide Registry Program via mail or fax.

Start filling out your form online today to ensure timely verification.