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South Carolina Nurse Aide PDF Template

The South Carolina Nurse Aide form is an essential document for individuals seeking to be listed on the North Carolina Nurse Aide I Registry through reciprocity. This form outlines the eligibility requirements and necessary steps for applicants, ensuring they meet the standards set by the state. Completing this form accurately is crucial, as any incomplete applications will not be processed.

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Outline

The South Carolina Nurse Aide form serves as a crucial document for individuals seeking to join the Nurse Aide I Registry in North Carolina through reciprocity. This application process is designed to ensure that applicants meet specific eligibility criteria before being listed. The form consists of several parts, beginning with a section that helps applicants determine their eligibility based on five key requirements. These include being in good standing on another state registry, having no substantiated findings of abuse or neglect, and demonstrating recent employment as a nurse aide. Additionally, applicants must provide personal information, including their legal name, Social Security number, and contact details. They must also confirm completion of a state-approved nurse aide training program and competency evaluation. The form requires applicants to list all states where they hold active or expired nurse aide registry listings and to provide documentation verifying their status. Lastly, employment history must be detailed, focusing on positions held in the past two years where nursing tasks were performed under the supervision of a registered nurse. Incomplete applications will not be processed, emphasizing the importance of thoroughness in filling out the form.

Form Sample

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
□ YES	□ NO	75 Hours of Training?
		75 Hours of Training?

□ YES	□ NO	Did You Successfully Pass a State-Approved Nurse Aide I Competency Examination?
□ YES	□ NO

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	______/______/______			______/______/______
	□ 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	______/______/______			______/______/______
	□ 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	______/______/______			______/______/______
	□ 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?
□ YES □ NO

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

↓ South Carolina Nurse Aide

File Breakdown

Fact Name	Details
Governing Law	This form is governed by Rule 10A NCAC 13O .0301.
Application Review Time	The Department of Health Service Regulation (DHSR) has 10 business days to review the application from the date of receipt.
Eligibility Criteria	Applicants must meet five specific criteria to be eligible for listing on the Nurse Aide I Registry.
Active Status Requirement	Applicants must be listed as active and in good standing on another state registry of nurse aides.
Employment History	At least eight hours of paid nursing or nursing-related tasks supervised by a Registered Nurse must have been completed in the past two years.
Identification Requirements	Applicants must provide a social security card and a government-issued ID with a matching name.
Training Program	Completion of a state-approved nurse aide training program is required, meeting federal standards.
Application Submission	Applications must be completed using black or blue ink and can be submitted by mail or fax.
Multiple Applications	Only one application should be submitted unless instructed otherwise by DHSR.
Documentation for Reciprocity	Documentation verifying active status on other state registries must be included and dated within 30 days of application submission.

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