Form Sfn 50645 – Fill Out and Use This PDF

Social Security Number

Certified in the following states:

Last Date Worked (Indicate State)

1.____________________________________

1.____________________________________________

2.____________________________________

2.____________________________________________

3.____________________________________

3.____________________________________________

4.____________________________________

4.____________________________________________

Nurse Aide Registry Number

1)

2)

3)

4)

First Name

Last Name

Maiden/Middle

M / F

Date of Birth

Current Mailing Address

City

State

Zip

County

Daytime Phone

ALL QUESTIONS MUST

BE REG

E-Mail Address

ND CNA # if Applicable

Nurse Aide Program Completed: Facility Name, and City

Date Completed

Today’s Date

ALL QUESTIONS MUST BE COMPLETED BY REGISTRANT

Have you ever been arrested, charged, or convicted of a felony (You must answer yes if the

1.

felony arrest or felony charge resulted in a plea agreement, misdemeanor, nolo contendere,

฀ Yes

฀ No

deferred imposition, or other action) within the last two years?

2.

Since you last renewed, or if this is your first renewal, has your registration or nursing

฀ Yes

฀ No

license been sanctioned or disciplined by any other jurisdiction?

Since you last renewed, or if this is your first renewal, have you had a nurse aide registry

฀ Yes

฀ No

3.

listing or unlicensed assistive person registry listing marked for abuse, neglect, or

misappropriation of property?

4.

Since you last renewed, or if this is your first renewal, have you been investigated or are you

฀ Yes

฀

No

presently being investigated by any other jurisdiction?

5.

Since you last renewed, or if this is your first renewal, have you been denied registration or

฀ Yes

฀ No

licensure by any other jurisdiction?

6.

Have you, in the last two (2) years, been terminated from a nurse aide or nursing related job

฀ Yes

฀ No

due to conduct that may be grounds for disciplinary action?

7.

Have you, in the last two (2) years, been diagnosed with chemical dependency or

฀ Yes

฀ No

participated in chemical dependency treatment/rehabilitation?

Have you, in the last two (2) years, been diagnosed with or treated for a mental health or

฀ Yes

฀ No

8.

physical condition which adversely affected your ability to safely provide nurse aide

services?

If you answered “Yes” to any of the above questions, please attach a detailed written explanation and

฀

฀

฀

9.

any legal documents to the application and send to the North Dakota Department of Health for review.

Yes

No

NA

Have you attached the appropriate documents?