Nursing Assistant Certified Endorsement Application

1 Nursing Assistant Certification Endorsement Application Packet Contents: 1. List/SSN Information/Mailing page 2. Instructions 2 pages 3. 4 pages 4. Assistant Certification 5 pages 5. RCW/WAC and Online Website page Important Social Security Number Information: You are required by state and federal law to provide a social security number with your Application . If you do not have a social security number at the time you send in this Application , please read, complete, and return this form with your Application . A Individual Taxpayer Identification Number (ITIN) or a Canadian Social Insurance Number (SIN) cannot be substituted. In order to process your request: Mail your Application with initial documentation and your check Send other documents not sent with or money order payable to: initial Application to: Department of Health Nursing Assistant Credentialing Box 1099 Box 47877. Olympia, WA 98507-1099 Olympia, WA 98504-7877.

2 Contact us: 360-236-4700. DOH 667-039 March 2017 (This page intentionally left blank.). Application Instructions Checklist Important background check Information: Washington State law authorizes the Department of Health to obtain fingerprint-based background checks for licensing purposes. This check may be through the Washington State Patrol and the Federal Bureau of Investigation (FBI). This may be required if you have lived in another state or if you have a criminal record in Washington State. This would be at your own expense. All information should be printed clearly in blue or black ink. It is your responsibility to submit the required forms. FF Application Fee. This fee is non-refundable. You can check the online fee page for current fees. FF Check one that applies: Check which type of training you have completed. FF Check if either apply: Request for Military Training and Experience Evaluation Spouse or Registered Domestic Partner of Military Personnel FF 1.

3 Demographic Information: Social Security Number: You must list your social security number on your Application . Please call the Customer Service Center at 360-236-4700 if you do not have one. National Provider Identifier Number (NPI): The National Provider Identifier (NPI). is a standard unique identifier for health care professionals available from the Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric identifier. If you have a NPI number, provide this on your Application . Legal Name: List your full name: first, middle, and last. Definition of legal name: Legal name is the name appearing on your official certificate of birth or, if your name has changed since birth, on an official marriage certificate or an order by a court. The court must have the legal authority to change your name. We may ask you to prove your legal name. If you use any name other than your legal name on this form, your Application may be denied.

4 Birth date: Provide the month, day, and year of your birth. Address: List the address we should use to send any information about your li- cense. Be sure to include the city, state, zip code, county, and country. This will be your permanent address with the Department of Health until we have been notified of a change. See WAC 246-12-310. Phone, Fax, and Cell Numbers: Enter your phone, fax, and cell numbers, if you have them. Email: Enter your email address, if you have one. Other Name(s): Indicate whether you are known or have been known under any other names. If you have a name change, you must notify the Department of Health in writing. You must include proof of this change. See WAC 246-12-300. DOH 667-030 March 2017 Page 1 of 2. FF 2. Personal Data Questions: All applicants must answer the same personal data questions. They are focused on your fitness to practice the essential skills of this profession.

5 If you answer yes to any questions in this section, you must provide an appropri- ate explanation. You must also provide the documentation listed in the note after the question. If you do not provide this, your Application is incomplete and it will not be considered. Question 5 includes misdemeanors, gross misdemeanors and felonies. You do not have to answer yes if you have been cited for traffic infractions. You can get copies of court records through the county courthouse where the conviction, plea, deferred sentence, or suspended sentence was entered. If you have been granted certificate(s) of restoration of opportunity, please provide a Certified copy of each certificate. Another jurisdiction means any other country, state, federal territory, or military authority. FF 3. Education and Training: List in date order, most recent to later, the name and location of each college, university, technical or professional school and practice that applies to your profession.

6 FF 4. Caregiver Employment History (to be completed by Endorsement applicants): List the last place of caregiver employment, where you worked in the state that you are endorsing from. Include the business name, address, the first and last days of employment, and the last two states where your name appears on the OBRA. registry. FF 5. Certifying Organization (to be completed if applying by alternative training as a medical Assistant ): Select which organization you hold a current medical Assistant certification. FF 6. Examination Data: For applicants who have taken the National Nurse Aide Assessment Program (NNAAP) examinations in Washington list the date passed the written/oral and skills examinations. Not applicable for applicants applying by Endorsement . FF 7. Other License, Certification, or Registration: List all states, including Washington, where credentials are or were held. Attach additional completed pages if you need more space.

7 You must also print the Verification Form and provide it to each state or jurisdiction that you have listed, requesting that they complete and submit the form directly to the Department of Health. FF 8. AIDS Education and Training Attestation: Read the AIDS education and training attestation. AIDS training may include self- study, direct patient care, courses, or formal training. A minimum of seven hours is required. Course content can be found in WAC 246-12-270. If AIDS education was included in your professional education or training, an additional course is not required. FF 9. Applicant's Attestation: You must sign and date this for us to process the Application . DOH 667-030 March 2017 Page 2 of 2. Certification Requirements Traditional Training Submit Application and fee Submit a copy of your certificate of completion from an approved training program. See the list of approved programs.

8 Have successfully passed the nurse aide competency examinations. Alternative Training - Home Care Aide If you are a Certified home care aide seeking Nursing Assistant -certification, refer to WAC 246-841-585 for alternative program Application requirements. Submit Application and fee. Submit a copy of your certificate of completion from an approved Home Care Aide bridge program. See the list of approved programs. Documentation verifying current certification as a home care aide under Chapter RCW Evidence of completion of seven hours of AIDS education and training. Complete a cardiopulmonary resuscitation (CPR) course. Provide a copy of the front and back of your current card as proof of completion. Have successfully passed the nurse aide competency examinations. Alternative Training - Medical Assistant - Certified If you are a medical Assistant Certified as defined in WAC 246-841-535 seeking Nursing Assistant -certification, refer to WAC 246-841-585 for alternative program Application requirements.

9 Submit Application and fee. Submit a copy of your certificate of completion from an approved Medical Assistant - Certified bridge program. See the list of approved programs. Evidence of completion of seven hours of AIDS education and training. Submit official transcripts from the nationally accredited medical Assistant program you completed. Documentation verifying current medical Assistant certification from one of the following certifying organizations: -- American Association of Medical Assistants (AAMA). -- American Medical Technologists (AMT). -- National Healthcareer Association (NHA). -- National Center for Competency Testing (NCCT). Complete a cardiopulmonary resuscitation (CPR) course. Provide a copy of the front and back of your current card as proof of completion. Have successfully passed the nurse aide competency examinations. DOH 667-047 March 2017 Page 1 of 4. Nursing Assistant Certification by Interstate Endorsement If you hold an active Nursing Assistant Certification in another state, you may qualify for certification in Washington by Endorsement .

10 Submit Application and fee. Provide caregiver employment history from the state you're endorsing from by completing section four of the Application . Include the business name, address, and the first and last days of employment. If you do no have caregiving employment history mark this section as not applicable (N/A). If left blank, this could delay the processing of your Application . Evidence of completion of seven hours of AIDS education and training. Verification of current Nursing Assistant certification from the state you're coming from. Complete part one of the Out-of-state Verification Form and send it to the state you are endorsing from. That state will complete section two of the verification form and mail it directly to Washington State. Contact information for other states can be found on the Out of State NAC Registries website. Note: you will be required to submit verification of all health care registrations, certifications, and licenses in any other state or jurisdictions.