Form 5510 Natcep – Fill Out and Use This PDF

I.Use this form to request approval to take the CEP in Texas if you have:

•successfully completed at least 100 hours of training at a NATCEP in another state within the preceding 24 months, but have not taken the competency evaluation or been placed on a Nurse Aide Registry in another state;

•not completed the CEP or have been placed on the Nurse Aide Registry in another state; and

•met CEP requirements listed at §94.11(c)(2)-(3) 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 §205.006 will be eligible for the CEP. Chapter 250 and a list of convictions can be found at: http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.250.htm.

Nurse Aide Training Program staff will complete the EMR check. However, individuals requesting to take the CEP must request 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 this application to receive approval to take the test.

II.Complete Items A through Q (type or fill out electronically) A. Name (Last, First, Middle)

I.Name of Facility, if employed

J.Address of Facility (Street, City, State, ZIP Code)

K.Name of Training Program

L.Address of Training Program (Street, City, State, ZIP Code)

M.Dates of Training (mm/dd/yyyy)

III.Applicant must attach proof of successful completion of a Nurse Aide Training Program approved in another state. This proof must be a photocopy of an original certificate of completion that has been notarized as a true and exact copy of an unaltered original.

IV. If the name on the certificate is different than the name in Item II-A, applicant must attach proof of name change, such as a photocopy of a marriage license, divorce paper or legal name change document.