South Carolina Nurse Aide Form PDF Details

The South Carolina Nurse Aide form, also called the NACES form, is a document that must be completed by all nurse aides who work in the state of South Carolina. The form is used to ensure that all nurse aides are properly qualified and have the necessary training to provide safe and quality care to patients. In order to complete the form, nurse aides must provide information about their education and training, as well as their current certification status. The NACES form must be renewed annually, and failure to renew it may result in disciplinary action.

Below is the details relating to the file you were in search of to complete. It will tell you how much time you'll need to fill out south carolina nurse aide form, what fields you will have to fill in, and so on.

QuestionAnswer
Form NameSouth Carolina Nurse Aide Form
Form Length6 pages
Fillable?Yes
Fillable fields74
Avg. time to fill out16 min 22 sec
Other namescna renewal form, nurse aide registry renewal form, cna license renewal sc, cna renewal sc

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North Carolina Department of Health and Human Services

Division of Health Service Regulation

Health Care Personnel Education and Credentialing Section

Phone: 919-855-3969

NURSE AIDE I REGISTRY RECIPROCITY APPLICATION

DHSR Has 10 Business Days from Date of Receipt to Review the Application.

INSTRUCTIONS:

Review Part 1 below and determine if you meet the eligibility requirements to be listed on the North Carolina Nurse Aide I Registry.

If you meet the eligibility requirements, then complete and submit all pages of the application (pages 1 through 6) and any required supportive documentation. Incomplete applications will not be processed.

Please use black or blue ink only. Other ink colors are not be readable via fax. Return completed application by mail or fax.

oMailing Address: 2709 Mail Service Center, Raleigh, NC 27699-2709

o Fax Number: 919-733-9764

Do Not Submit More Than One (1) Application Unless Instructed by DHSR.

PART 1: DETERMINE ELIGIBILITY

Consistent with Rule 10A NCAC 13O .0301, to be eligible to be listed on the North Carolina Nurse Aide I Registry, you must meet the five (5) criteria listed below.

1.You are listed as active and in good standing on another State registry of nurse aides.

o A temporary listing on a State registry of nurse aides will not be accepted.

2.You have no pending or substantiated findings of abuse, neglect, exploitation, or misappropriation of resident or patient property recorded on any State registry of nurse aides.

3.You have been employed as a nurse aide for monetary compensation consisting of at least a total of eight hours of time worked performing nursing or nursing-related tasks delegated and supervised by a Registered Nurse in the past two years (previous 24 consecutive months).

oIf you have not been employed as a nurse aide, then you are only eligible for reciprocity if you successfully passed a state-approved nurse aide I competency examination and was listed on the Nurse Aide I Registry in the State(s) of reciprocity in the past two years (previous 24 consecutive months).

oPrivate duty nurse aide employment type does not meet the eligibility requirements for reciprocity.

4.You have a social security card and an unexpired government-issued identification containing a photograph and signature.

oThe name listed on your social security card and unexpired government-issued identification containing a photograph and signature must match.

oThe name listed on both identifications must match the name listed on the nurse aide registry in the State(s)

of reciprocity.

oIf the names do not match, then you must submit documentation verifying any name changes (e.g., birth certificate, marriage license, divorce decree, notice of resumption of former name, etc.).

5.You completed a state-approved nurse aide training and competency evaluation program that meets the requirements of 42 CFR 483.152 or a state-approved competency evaluation program that meets the requirements of 42 CFR 483.154.

DHSR/HCPEC-4515 (Revised February 2021)

Page 1 of 6

PART 2: PERSONAL INFORMATION

Answer all questions. Print legibly.

Include hyphens and suffixes in your legal name if applicable (No Nicknames).

First Name:

Middle Name:

Last Name:

Prior Name(s) (if applicable):

First Name:

 

 

Middle Name:

 

 

Last Name:

 

 

 

 

 

 

 

First Name:

 

 

Middle Name:

 

 

Last Name:

 

 

 

 

 

 

 

 

 

 

 

 

Gender:

 

 

Social Security Number:

 

Email Address:

 

 

 

(include all 9 numbers)

 

 

MALE

FEMALE

 

 

 

 

 

 

 

 

 

 

 

Telephone Number:

 

Date of Birth:

 

 

Mother’s Maiden Last Name:

(include area code)

 

 

 

 

 

 

 

 

_________/________/__________

 

 

 

 

mm

dd

yyyy

 

 

 

 

 

 

 

Did You Serve in the Military?

 

 

 

 

YES

NO

 

 

 

 

Did You Work in a Military Occupational Specialty (MOS) Where You Performed Nursing or Nursing-Related Tasks?

YES NO I DID NOT SERVE IN THE MILITARY

Are You Currently Married to an Active Member of the Military or a Military Veteran?

YES NO

Mailing Address:

Street/PO Box:

City:

Zip Code:

Apt. #:

State:

County:

DHSR/HCPEC-4515 (Revised February 2021)

Page 2 of 6

PART 3: STATE-APPROVED NURSE AIDE I TRAINING & COMPETENCY EVALUATION PROGRAM

Answer both questions below.

YES

NO

Did You Complete a State-Approved Nurse Aide I Training Program that Consisted of At Least

75 Hours of Training?

 

 

 

 

 

YES

NO

Did You Successfully Pass a State-Approved Nurse Aide I Competency Examination?

 

 

 

 

PART 4: NURSE AIDE I REGISTRIES

Complete the table and questions below.

List all states that you have an active or expired nurse aide I registry listing. We will verify that you have no findings in the states where your listing is active or expired.

For all active listings, you must include, with this application, documentation verifying that each registry listing is active and in good standing in the State of reciprocity. The documentation should be dated within 30 calendar days before the date your application is received by the Department.

If your listing is active and you are currently working as a nurse aide in Alabama, then you must submit a signed letter from your current employer, on official company letterhead, indicating your nurse aide status is active in the state of Alabama.

State Name or

 

Is Your Registry

Original Issue Date:

Expiration Date:

Registry Certification or

Abbreviation:

 

 

Listing

 

 

 

 

 

 

Registration Number:

 

 

Current/Active?

 

 

 

 

 

 

 

 

 

YES

NO

______/______/______

______/______/______

 

 

 

mm

dd

yyyy

mm

dd

yyyy

 

 

 

 

 

 

 

 

State Name or

 

Is Your Registry

Original Issue Date:

Expiration Date:

Registry Certification or

Abbreviation:

 

 

Listing

 

 

 

 

 

 

Registration Number:

 

 

Current/Active?

 

 

 

 

 

 

 

 

 

YES

NO

______/______/______

______/______/______

 

 

 

mm

dd

yyyy

mm

dd

yyyy

 

 

 

 

 

 

 

 

State Name or

 

Is Your Registry

Original Issue Date:

Expiration Date:

Registry Certification or

Abbreviation:

 

 

Listing

 

 

 

 

 

 

Registration Number:

 

 

Current/Active?

 

 

 

 

 

 

 

 

 

YES

NO

______/______/______

______/______/______

 

 

 

mm

dd

yyyy

mm

dd

yyyy

 

 

 

 

 

 

 

 

 

 

 

YES NO

 

Are You Listed on More Than Three State Nurse Aide Registries in an Active or Expired

 

 

 

Status?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you answered YES, then you must attach a separate sheet of paper providing the registry information for the States not listed in the table above.

DHSR/HCPEC-4515 (Revised February 2021)

Page 3 of 6

YES NO

Do You Have Any Pending or Substantiated Findings of Abuse, Neglect, Exploitation, or Misappropriation of Resident or Patient Property Recorded on Any State Registry of Nurse Aides?

If you answered YES to the question above, then list the States below.

States Where You Have a Pending or Substantiated Finding:

PART 5: EMPLOYMENT TYPE

Select the employment type where you performed nursing or nursing-related tasks delegated and supervised by a Registered Nurse in the past 2 years only (previous 24 consecutive months). Private duty nurse aide employment does not meet the eligibility requirements for reciprocity.

Select all that apply.

Adult/Family Care Home

Home Health/Home Care

Hospice

 

 

 

 

 

Hospital

Mental Health

Nursing Home

 

 

 

 

 

Other (please specify):

 

 

 

 

I Did Not Work as a Nurse Aide; I Successfully Passed a State-Approved Nurse Aide I Competency Evaluation

Program and Was Listed on the Nurse Aide I Registry in the State(s) of Reciprocity in the Past 2

Years (Previous

24 Consecutive Months).

 

 

 

 

 

 

 

PART 6: EMPLOYMENT HISTORY

Provide employment information where you performed nursing or nursing-related tasks delegated and supervised by a Registered Nurse in the past 2 years only (previous 24 consecutive months). Do not include private duty nurse aide employment.

If you did not work as a nurse aide, then leave blank.

FACILITY/AGENCY/EMPLOYER #1

Name:

 

 

 

 

 

 

 

 

Street/PO Box:

 

 

 

 

 

 

 

 

City:

 

State:

 

Zip Code:

 

 

 

Date of Hire as a Nurse Aide (month/year):

Last Reported Date of Employment as a Nurse Aide (month/year):

_____/_______

_____/_______

 

mm

yyyy

mm

yyyy

 

 

 

 

DHSR/HCPEC-4515 (Revised February 2021)

 

 

Page 4 of 6

YES NO

Is the Employer a Staffing Agency?

If you answered YES to the question above, then list the States below.

States Where You Worked for the Staffing Agency in the Past 2 Years (Previous 24 Consecutive Months):

YES

NO

Did You Work as a Nurse Aide for Monetary Compensation (i.e., For Payment or For Wages)

 

 

in the Past 2 Years (Previous 24 Consecutive Months)?

 

 

 

YES

NO

Did You Work At Least 8 Hours Performing Nursing or Nursing-Related Tasks Delegated

 

 

(i.e., Assigned) and Supervised by a Registered Nurse in the Past 2 Years (Previous 24

 

 

Consecutive Months)?

 

 

 

If you answered YES to either question above, then provide the First and Last Name of the Registered Nurse. It is not required that the RN sign below.

Registered Nurse First Name and Last Name:

FACILITY/AGENCY/EMPLOYER #2

Name:

Street/PO Box:

City:

 

 

State:

 

Zip Code:

 

 

 

 

Date of Hire as a Nurse Aide (month/year):

Last Reported Date of Employment as a Nurse Aide (month/year):

_____/_______

 

_____/_______

 

mm

yyyy

 

mm

yyyy

 

 

 

 

 

 

YES NO

Is the Employer a Staffing Agency?

 

 

 

 

 

 

 

 

 

 

 

 

If you answered YES to the question above, then list the States below.

States Where You Worked for the Staffing Agency in the Past 2 Years (Previous 24 Consecutive Months):

YES

NO

Did You Work as a Nurse Aide for Monetary Compensation (i.e., For Payment or For Wages)

 

 

in the Past 2 Years (Previous 24 Consecutive Months)?

 

 

 

 

YES

NO

Did You Work At Least 8 Hours Performing Nursing or Nursing-Related Tasks Delegated

 

 

(i.e., Assigned) and Supervised by a Registered Nurse in the Past 2 Years (Previous 24

 

 

Consecutive Months)?

 

 

 

 

DHSR/HCPEC-4515 (Revised February 2021)

Page 5 of 6

If you answered YES to either question above, then provide the First and Last Name of the Registered Nurse. It is not required that the RN sign below.

Registered Nurse First Name and Last Name:

NOTE:

You must attach a separate sheet of paper if you had more than two employers where you performed nursing or nursing- related tasks delegated and supervised by a Registered Nurse in the past 2 years only (previous 24 consecutive months). Do not include private duty nurse aide employment.

PART 7: IDENTIFICATION

Include a copy of your social security card with the submission of your application.

Include a copy of an unexpired government-issued identification containing a photograph and signature with the submission of your application.

The name listed on your social security card and unexpired government-issued identification containing a photograph and signature must match.

The name listed on both identifications must match the name listed on the nurse aide registry in the State(s) of reciprocity.

If the names do not match, then you must submit documentation verifying any name changes (e.g., birth certificate, marriage license, divorce decree, notice of resumption of former name, etc.).

Copies of identifications received by fax may not be readable. Please ensure copies of your identifications are readable before submitting your application. If your identifications are not readable, then you will be asked to re-submit the application and your identifications again.

The Following are Acceptable Government-Issued Identifications Containing a Photograph and Signature:

Current, non-expired driver’s license (or expired driver’s license and temporary permit)

U.S. government-issued Military I.D.

State-issued identification card

Passport (US or foreign, current, non-expired)

Current, non-expired federal-issued employment authorization document (EAD) photo identification card

Alien registration card

PART 8: APPLICANT SIGNATURE

I certify that all the information provided in this application is true and complete. I understand that if the information I have provided in this application is found to be fraudulent, then my listing will be removed from the North Carolina Nurse Aide I Registry and I will be required to pass a North Carolina state-approved nurse aide I training program and the North Carolina state-approved nurse aide I competency examination. I give my permission to any state registry to disclose all information requested in this application to the North Carolina Division of Health Service Regulation, Health Care Personnel Education and Credentialing Section.

First Name (print): _________________________________________________________________________________

Middle Name (print): _______________________________________________________________________________

Last Name (print): _________________________________________________________________________________

Signature: _________________________________________________ Date: ________________________________

REMINDER:

You Must Submit All Pages of the Application (Pages 1 through 6), Your Social Security Card, and a Current Government-Issued Identification with Photograph and Signature for Review and Approval.

DHSR/HCPEC-4515 (Revised February 2021)

Page 6 of 6

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You should enter the following details to prepare the sc nurse aide registry renewal form PDF:

filling in sc cna renewal stage 1

Feel free to complete the YES, NO Mailing, Address Street, PO, Box, City Zip, Code Apt, State, County, and DHS, RHCP, EC, Revised, February, Page, of box with the essential information.

Finishing sc cna renewal step 2

It is crucial to record certain details in the space YES, NO YES, NO and PART, NURSE, AIDE, I, REGISTRIES

Entering details in sc cna renewal part 3

Inside of field Registry, Certification, or Registration, Number Registry, Certification, or Registration, Number State, Name, or, Abbreviation State, Name, or, Abbreviation YES, NO mm, dd, yyyy mm, dd, yyyy Is, Your, Registry Original, Issue, Date Expiration, Date Listing, Current, Active and YES, NO indicate the rights and responsibilities.

Filling in sc cna renewal step 4

Finish the form by looking at these areas: YES, NO PART, EMPLOYMENT, TYPE Select, all, that, apply Adult, Family, Care, Home Home, Health, Home, Care Hospice, Hospital, Mental, Health and Nursing, Home

Filling out sc cna renewal part 5

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Step 4: In order to prevent any specific challenges as time goes on, try to get a minimum of a few copies of the document.

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