Form 5507 Nar PDF Details

In an era where the healthcare sector continues to demand qualified personnel, navigating the bureaucratic processes to maintain or acquire the necessary credentials becomes a pivotal task for individuals in the nursing field. The Texas Department of Aging and Disability Services revised the 5507-NAR form in July 2014, unveiling a streamlined approach for nurse aides striving to bypass traditional training routes through a waiver request. This form caters specifically to those who have previously completed a nurse aide training program consisting of 100 or more hours before July 1, 1989, and have consistently provided nursing or nursing-related services for compensation since that time. Applicants are urged to carefully complete Section 1, ensuring all personal details are accurate and to sign off confirming the correctness of the provided information. Additionally, the form requires submission of crucial documents including criminal history results, identification proofs, employment verification via Form 5506-NAR, and evidence of completed training. Importantly, eligibility hinges not only on the fulfillment of these requirements but also on the absence of the applicant's name from the Employee Misconduct Registry (EMR) and a clean slate regarding specific criminal offenses. Mailing all requisite information to the specified address completes this initial step toward potential exemption from further training and assessment, bringing applicants a step closer to their goal within the Texas healthcare system. Significantly, tampering or attempting to falsify government records associated with this process is severely punishable, underscoring the importance of honesty and accuracy in every submission.

QuestionAnswer
Form NameForm 5507 Nar
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names5507 nar, yyyy, tlo2, EMR

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Texas Department of Aging

Form 5507-NAR

and Disability Services

July 2014-E

Texas Nurse Aide Registry

Request for Waiver of Nurse Aide Training

and Competency Evaluation

Section 1. Application Information (to be completed by applicant)

Note: You will not receive a new certificate if you are only updating your certification expiration date. To verify your CNA number or that your expiration date has been extended, call 1-800-452-3934.

Please read the following instructions before completing this form.

Complete all information in Section 1 and sign to verify that the information provided is correct.

Attach your criminal history results for the Department of Public Safety (DPS), a legible photocopy of a picture identification that shows your birth date and the correct spelling of your name.

Attach a completed Form 5506-NAR, Employment Verification, showing you provided nursing/nursing-related services at least every two years since July 1, 1989, to present for monetary compensation.

Attach an official or notarized copy of your certificate of completion or transcript that shows you completed a nurse aide training consisting of 100 or more hours before July 1, 1989; or program director, program trainer or official keeper of records completes Section 2.

Individuals who are requesting to be placed on the Texas Nurse Aide Registry by waiver must meet eligibility requirements listed at §94.11 (a)(1-5) of the Licensing Standards for Nurse Aides. No individual listed as unemployable on the Employee Misconduct Registry (EMR) or who has been found to have a conviction of a criminal offense listed in Texas Health and Safety Code §250.006 will be eligible for the waiver. Chapter 250 and a list of convictions can be found at: http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.250.htm#00.

Mail all required information to: Texas Nurse Aide Registry, P.O. Box 149030, MC E-414, Austin, TX 78714-9030.

Name (Last, First, Middle)

 

 

 

 

Maiden Name (if applicable)

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

Sex

 

 

Social Security No.

 

 

 

Male

Female

 

 

 

 

Mailing Address (Street or P.O. Box)

 

 

 

 

Area Code and Telephone No.

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

Name of Training Program

 

 

 

Date Training Began:

Date Training Completed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature – Applicant

 

 

 

Date

 

 

 

Section 2. Affidavit of Training (to be completed by training program director, trainer or official records keeper)

Instructions:

Complete information requested below and provide authorized signature.

Notarize signature.

Return document to the nurse aide applicant.

Has the applicant successfully completed a nurse aide training course?..................................................................................

The training course included

 

hours of nurse aide training.

Yes

No

Nurse aide training was completed before July 1, 1989. Dates

of training were from

 

 

 

to:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Training Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area Code and Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (Street or P.O. Box)

 

 

 

 

 

 

City

 

 

State

 

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Official Completing Form

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature – Official

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

Sworn and subscribed to me on this

 

day of

 

 

, 20

 

 

,

 

 

 

 

 

 

in

 

 

County, in the state of

 

 

.

 

 

 

 

 

 

 

 

 

 

 

Signature – Notary Public

Date Commission Expires

Notes:

The Texas Nurse Aide Registry will return (without action) incomplete requests and requests without required documents.

Tampering with or attempting to falsify a government record as such a nurse aide certificate is a third-degree felony punishable by up to 10 years in prison and a $10,000 fine.

Form 5507-NAR

Page 2 / 07-2014-E

Address:

To meet waiver eligibility requirements, Nurse Aide Registry staff will complete the EMR check. However, the individual requesting a waiver must obtain a criminal history check from the Texas Department of Public Safety (DPS). For instructions on how an individual can obtain a criminal history check, contact your local DPS office or visit the website: www.txdps.state.tx.us/administration/crime_records/pages/faq.htm. You must submit your criminal history results along with the waiver Form 5507-NAR to receive approval to be placed on the Texas Nurse Aide Registry by waiver.

sign the form?

include your criminal history results, a legible photocopy of your picture identification showing your birth date and the correct spelling of your name?

include completed Form 5506-NAR, Employment Verification, for each nursing/nursing-related service you provided for monetary compensation at least every two years since July 1, 1989?

Did training program director. trainer or official records keeper:

complete Section 2?

sign the affidavit?

notarize the signature?

Did you know?

You can verify certificate status by calling 1-800-452-3934.

You can download forms from our website: http://www.dads.state.tx.us/providers/nf/credentialing/nar/forms.html

Texas Nurse Aide Registry

Mail Code E-414

P.O. Box 149030

Austin, Texas 78714-9030

credential@dads.state.tx.us

With a few exceptions, you have the right to request and be informed about the information that the Department of Aging and Disability Services (DADS) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask DADS to correct information that is determined to be incorrect (Government Code, Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, please contact the Nurse Aide Registry at 512-438-2050.

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This document will require specific details; to ensure accuracy and reliability, please make sure to heed the tips listed below:

1. While filling in the credentialing, make certain to include all needed blanks within its corresponding part. This will help expedite the process, which allows your details to be processed swiftly and properly.

A way to complete tlc stage 1

2. Just after this array of blanks is filled out, go to type in the applicable details in these - Name of Training Facility, Address Street or PO Box, Name of Official Completing Form, City, Title, Area Code and Telephone No, State, ZIP Code, Signature Official, Date, Sworn and subscribed to me on this, day of, County in the state of, Notes The Texas Nurse Aide, and and a fine.

Step number 2 in submitting tlc

3. This subsequent segment is generally rather simple, Address, To meet waiver eligibility, sign the form include your, spelling of your name, and include completed Form NAR - each one of these blanks has to be completed here.

Writing section 3 of tlc

4. You're ready to fill out this fourth part! Here you'll get all of these Did you know You can verify, Texas Nurse Aide Registry, Mail Code E PO Box, Austin Texas, credentialdadsstatetxus, and With a few exceptions you have the blanks to complete.

Part number 4 of submitting tlc

People often make errors when completing Texas Nurse Aide Registry in this section. Be certain to read twice whatever you type in here.

Step 3: You should make sure the information is correct and then just click "Done" to complete the task. Try a free trial subscription at FormsPal and acquire direct access to credentialing - download or modify in your FormsPal account. We don't share or sell any information you enter while dealing with documents at our website.