Texas Form 5506 Nar – Fill Out and Use

	Form 5506-NAR
Texas Nurse Aide Registry	March 2018-E

Employment Verification

Please complete document in blue ink only.

Section 1. To be completed by Nurse Aide - Please read the following instructions before completing this form.

The Nurse Aide Registry has implemented a new online system called Credential Manager. Before completing this form, you are required to verify your information in the new system at: https://i7lp.integral7.com/txna. Click on "Up For Renewal but Never Logged In" and complete your registration. Once you have registered, please list your identification number here:

I.D. No.:

●Complete all information in Section 1 and sign to verify that the information provided is correct.

●Attach a legible photocopy of a picture identification that shows your birth date and the correct spelling of your name.

●Obtain employer verification (Section 2). Form must be mailed to: Texas Nurse Aide Registry, P.O. Box 149030, Mail Code E-414, Austin, TX

78714-9030. Faxes and copies will not be processed. To verify your Certified Nurse Aide (CNA) number, use the following link: https://emr.dads.state.tx.us/DadsEMRWeb/.

Note: A list of approved in-service education programs can be found at: https://hhs.texas.gov/nar-cbts or https://hhs.texas.gov/nar-approved- inservice

The Texas Nurse Aide Registry will return (without action) incomplete requests and requests without the required documents.

Name of Applicant (Last, First, Middle)				Maiden Name (if applicable)
Mailing Address (Street or P.O. Box)
City	State	ZIP Code			Daytime Area Code and Telephone No.
Social Security No.	Sex		Date of Birth (mm/dd/yyyy)		Email Address
	Male	Female
CNA Certificate No.

Note: In-service education requirements are subject to audit. Be prepared to submit in-service certificates if contacted by Texas Health and Human Services Commission (HHSC).

Signature – Nurse Aide

Date

Section 2. To be completed by the Employer - Instructions:

●This section must be completed by the facility program director, official keeper of records or actual employer.

●Notarize employer signature at the bottom of this section and return to nurse aide.

I certify that the individual named above is/was employed by me as a nurse aide and performed nursing/nursing-related services

from (mm/dd/yyyy)

to (mm/dd/yyyy)

and that I am not aware of any disqualifying misconduct.

Comments:

Signature – Employer

Date

Sworn and subscribed to me on this

day of

, 20

,

in

County, in the state of

.

Tampering with or attempting to falsify a government record as such a nurse aide certificate is a third-degree felony punishable by up to 10 years in prison and a $10,000 fine.