Form 5507 Nar – Fill Out and Use This PDF

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

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.