South Carolina Nurse Aide Form – Fill Out and Use This PDF

South carolina nurse aide Program

inStructionS for the nurse aide registry renewal form

Federal and state regulations require that in the past 24 months you have performed nursing or nursing-related services for pay, under the su- pervision of an RN or LPN. The Nurse Aide Registry Renewal Form is used to report your nurse aide employment history in order to maintain your eligibility to work in certain federally certified facilities. Failure to report your most recent date of employment to the Registry will affect your employment eligibility. Your personal information will be used only to identify and update your Registry records.

Allow two (2) weeks for processing your completed form. You may check the status of your renewal Form on the Nurse Aide Registry by going to the South Carolina Nurse Aide page on the Pearson VUE website (www.pearsonvue.com).

Section i — PerSonal information

1.Social Security Number: Enter the Social Security number that was previously used on the Nurse Aide Registry. Providing your Social Secu- rity number is voluntary. Social Security numbers are used to determine nurse aide employment eligibility for prospective employers.

2.Name on Certificate: Enter your current full name (last, first, and middle initial). Do NOT use nicknames (for example, enter “William” instead of “Bill”, “Jennifer” instead of “Jenny”, etc.).

3.Current Mailing Address: Enter your current address (street, P.O. box, city, state, and ZIP) in the boxes provided.

4.Current Home/Work Telephone Number: Enter your current home and work telephone numbers.

5.Certification Number & Expiration Date: Enter the number and expiration date found on your Nurse Aide Certificate.

6.Nurse Aide Signature: Sign and date the form.

Section ii — changeS to PerSonal information

To change or correct your name or Social Security number, attach a photocopy of a legal document that will provide proof of your new information (for example, marriage license, divorce decree, driver’s license, Social Security card). Your information will not be changed on the Registry unless you provide this documentation.

7.NEW Social Security Number: If your Social Security number has been changed, enter your new Social Security number.

8.CURRENT Name: If your name has been changed and no longer matches the name on your Nurse Aide Certificate, enter your new name (for example, a newly-married name, name change, etc.).

Section iii — to be comPleted by the current or moSt recent nurSe aide emPloyer

9.Name of Health Care Facility: Enter the name, city, state, and telephone number of your health care facility. Enter a Sponsor Code num- ber only if your facility is a Medicaid-certified nursing home.

10.Date of Hire: Enter the nurse aide’s starting date of employment at your facility. Date of Termination: Leave this section blank if the nurse aide is currently employed at your facility.

11.Work History: Check “Yes” or “No” if the nurse aide has provided nurse aide services for pay for at least 8 hours during the 24 months before their registration expiration date.

If “Yes”, enter the date the individual most recently worked as a nurse aide in a nursing-related service.

If “No”, this nurse aide does NOT qualify for renewal on the Nurse Aide Registry. Call the South Carolina state-approved training pro- gram where you completed your training to request an application to re-test. A list of South Carolina state-approved training programs may be found on the South Carolina Nurse Aide page at www.pearsonvue.com.

12.Declaration & Signature of Nurse Aide Employer: A representative of the employer must sign his/her name and date the form.

Section iV — renewal fee

13.Fee: If you are employed by a Medicaid-certified nursing home, the nursing home will pay the renewal fee. Please contact your employer to obtain a facility check for your renewal fee of $28. If you are employed by a facility other than a Medicaid-certified nursing home, you must pay the renewal fee yourself. Purchase a money order for $28, payable to Pearson VUE, and mail it with this completed form to the address below. The renewal fee is a processing fee and is not refundable.

mail the comPleted form with $28 fee to:

Pearson VUE – SC Nurse Aide Registry

PO Box 822749

Philadelphia, PA 19182-2749

After your application is received and approved, your record will be updated and you willl be mailed a new certificate and wallet card for the SC Nurse Aide Registry. If you do not qualify for continued enrollment, you will be mailed a denial letter, a Candidate Handbook for South Carolina, and an application to re-test in order to maintain your enrollment on the Registry.

Incomplete, unsigned, or illegible forms will not be processed. Forms must be mailed to the address above and may NOT be faxed. If you have any questions about completing this NA Registry Renewal Form, please contact the Registry at (800) 475-8290.