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 Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessouth carolina nurse aide registry, cna renewal form, cna license renewal sc, south carolina cna registry

Form Preview Example

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.

Copyright © 2010 Pearson Education, Inc., or its affiliates. All Rights Reserved.

Stock# 0741-03 11/10

South carolina nurse aide Program

nurSe aide regiStry renewal form

Before completing this form, read the instructions on the reverse side.

Section i – PerSonal information (Please print neatly in black ink)

1.Social Security Number (Use SSN listed on Nurse Aide Registry)

2.Name oN certificate (Do NOT use nicknames)

last

first

-

-

mi

3. curreNt mailing address

street (number and name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

apartment number

pO bOx

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

state

 

 

Zip COde

 

4.curreNt

Home Phone Number:

-

area COde

-

curreNt

Work Phone Number:

-

area COde

-

5.certificatioN Number

6.Signature – Nurse aide:

 

 

 

 

 

 

 

certificatioN eXPiratioN Date

 

 

-

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

mOnth

day

 

 

year

 

 

 

siGnature Of appliCant

 

 

 

 

date siGned

 

Section ii – changeS to PerSonal information

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

7. NeW Social Security Number

-

-

8. curreNt Name (Complete if your current name is different from the name on your Certificate)

last

first

mi

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

9. Name of HealtH care facility

city

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

SPoNSor coDe (if employer is a medicaid certified nursing home)

Phone

-

area COde

-

10.

Date of Hire

 

 

-

 

 

-

 

 

 

 

*Date of termiNatioN

 

 

-

 

 

-

 

 

 

 

*Leave blank if individual is

you

mOnth

 

day

 

 

year

 

 

mOnth

 

day

 

year

 

currently working for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Has the nurse aide been employed for pay, providing nursing-related duties for at least 8 consecutive hours during the

24 months before their registration expiration date? yes No

 

 

-

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

• if “yes”, enter the mOst reCent date that this individual worked as an aide providing

 

 

 

 

 

 

 

 

mOnth day

 

 

year

 

a nursing-related service:

 

 

 

 

 

 

 

 

 

 

 

 

 

if “no”, stOp here. this nurse aide does not qualify for renewal on the nurse aide registry. Call the South Carolina state- approved training program 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 – Nurse aide employer:

I verify that the information contained on this SC Nurse Aide Registry Renewal form is true and correct to the best of my knowledge.

siGnature Of emplOyer

title

date siGned

Section iV – renewal fee

If you are employed by a Medicaid certified nursing home, the nursing home will pay the recertification fee for you. Contact your em- ployer to obtain a facility check for $28. If you are NOT employed by a Medicaid certified nursing home, you must submit a

money order for $28. All fees should be made payable to “Pearson VUE”.

13.fee – $28 MAIL TO: Pearson Vue – Sc Nurse aide registry, pO box 822749, philadelphia, pa 19182-2749

Stock# 0741-03 11/10

Watch South Carolina Nurse Aide Form Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .