APPLICATION TO BE LISTED ON THE NC NURSE AIDE I REGISTRY ...
2709 Mail Service Center Raleigh, NC 27699-2709 Division of Health Service Regulation
Health Care Personnel Education and Credentialing Section
Phone: 919-855-3970 Fax: 919-733-9764
N.C. Department of Health and Human Services
APPLICATION TO BE LISTED ON THE NC NURSE AIDE I REGISTRY
(RNs or LPNs only)
Policy: RNs and LPNs may be listed on the Nurse Aide I Registry without competency testing if they have a current, unrestricted license to practice in North Carolina. RNs and LPNs undergoing disciplinary action may be listed if they have not been involved in the abuse, neglect or misappropriation of a resident's property and the North Carolina Board of Nursing (NCBON) supports a recommendation for working as a Nurse Aide I.
Social Security Numbers: In order to be listed you will need to provide your social security number, it will be used only as an identification number for record keeping and verification of your listing on the North Carolina Nurse Aide I Registry (Federal Regulation 483.156). The information on this application will be entered on the North Carolina Nurse Aide Registry and with the exception of your social security number will be a matter of public record.
Instructions: To apply for listing based on your RN or LPN license, complete the information below and fax or mail your completed application to the address above. Incomplete applications will not be accepted and your listing will be delayed if a completed application is not received. __________________________________________________________________________________
RN or LPN Information (Type or Print Clearly):
Name (as listed on nursing license): ___________________________________________________
Maiden Name: ________________________ Mother's Maiden Name: _______________________
Full Social Security Number: ________________ Date of Birth (Month/Day/Year): _______________
RN/LPN License Number: __________________ State of Issuance: _______________
License Type:
RN
LPN
If New Graduate, Date of Graduation: _______________
Mailing Address: Street or PO Box: __________________________ City: ____________________
State: ______ Zip: __________ Home Phone: _______________ Cell Phone: _______________
Work Phone: _______________ E-mail Address: _________________________________________
Have you ever been listed on NC Nurse Aide I Registry?
YES
NO
Include NC Listing # __________________
RN or LPN Signature* ___________________________________ Date: ______________________
*Disclosure ? By signing this form, you authorize and acknowledge the following: For the purpose of evaluating your request to be listed on the NC Nurse Aide I Registry, the Health Care Personnel Education and Credentialing Section will verify your license, including disciplinary actions, with the appropriate Board(s) of Nursing, including the NURSYS nurse licensure and disciplinary database if you are licensed in a compact state. No information obtained from the NURSYS or other license verification systems will be used in violation of any federal or state equal opportunity law or regulation. If your application is denied based on any information obtained from the NURSYS or other license verification system, you will be provided a copy of this information and the reason for denial.
DHSR/HCPEC 4502 (Rev. 9/2020) NCDHHS
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