Fillable Printable Nursing Assistant Registration Application Packet - Washington

Nursing Assistant Registration Application Packet - Washington

Nursing Assistant Registration Application Packet

Contents:

1. 667-025 ......Contents List/SSN Information/Mailing Information.......................1 page

2. 667-029 ......Application Instructions Checklist ................................................2 pages

3. 667-001 ......Nursing Assistant Registration Application .................................4 pages

4. 667-038 ......Out-of-State Credential Verification Form .....................................1 page

5. RCW/WAC and Online Website Links ..............................................................1 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 U.S. 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 checkSend other documents not

or money order payable to: sent with initial application to:

Department of Health Nursing Assistant Credentialing

P.O. Box 1099 P.O. Box 47877

Olympia, WA 98507-1099Olympia, WA 98504-7877

360-236-4700

DOH 667-025 July 2015

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DOH 667-029 July 2015 Page 1 of 2

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.

Application Fee. This fee is non-refundable. You can check the online fee page for

current fees.

1:Demographic Information:

Social SecurityNumber: 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.

NationalProviderIdentifierNumber(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.

Definitionoflegalname: “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.

Birth date:Provide the month, day, and year of your birth.

Birth place: Provide the city, state and country where you were born.

Address: List the address we should use to send any information about your

license. 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.

OtherName(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 ofthis change. See WAC 246-12-300.

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.

Application Instructions Checklist

DOH 667-029 July 2015 Page 2 of 2

If you answer “yes” to any questions in this section, you must provide an appropriate

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.

• Another jurisdiction means anyother country, state, federal territory, or military

authority.

3:OtherLicense,Certification,orRegistration:

List all states, including Washington, where credentials are or were held. Specifically

list credentials granted as temporary, reciprocity, exemption or similar with type,

date, grantor, and if credential is current. Attach additional completed pages if you

need more space.

4: AIDS Education and Training Attestation:

Read theAIDS 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.

5: Applicant’s Attestation:

You must sign and date this for us to process the application.

Other Information

Criminal history checks are conducted for all license applicants. If you answered

yes to anyof the personal data questions, please submit the appropriate supporting

documentation as indicated on the application. If your application is incomplete, you will

be mailed a letter regarding the deficiencies.

• The application is considered incomplete if requested information is left blank.

Write N/A or place a line through section instead of leaving blank.

• The initial registration will expire on your birthday unless the initial registration is

issued within 90 days of your next birthday.

• A courtesy renewal notice will be mailed to your address on record. You must

keep your address current with us. Any renewal postmarked or presented to the

department after midnight on the expiration date is late.

• Information regarding the Nursing Assistant program is available on our

Note: You cannot practice as a nursing assistant until your registration is issued.

Notice to Spouses and Registered Domestic Partners of

Military Personnel Transferring to Washington

Under state law, a spouse or registered domestic partner of military personnel transfer-

ring to Washington may receive his or her health professional license more quickly. In

order for us to do this, please submit the required military documentation with your ap-

plication for licensure found on your profession application and forms page.

Web Site.

DOH 667-001 July 2015 Page 1 of 4

Revenue029903000

Nursing Assistant Registered Application

Please print clearly in ink. It is the responsibility of the applicant to submit all required supporting

documentation. Failure to do so may result in a delay in processing your application.

1. Demographic Information

Social SecurityNumber(SSN)

(If you do not have a SSN, see instructions)

National Provider Identifier Number

(NPI)(Enter 10 digit number)

Male

Female

Name First Middle Last

Birth date (mm/dd/yyyy)

Place of birth

City StateCountry

Address

CityStateZip CodeCounty

Country

Phone (enter 10 digit #)Fax (enter 10 digit #)Cell (enter 10 digit #)

Email address

Mailing address (if different from above)

CityStateZip CodeCounty

Country

Note: The mailing and email addresses you provide will be your addresses of record. It is your

responsibility to maintain current contact information with the department.

Have you ever been known under any other name(s)?

Yes

If yes, list name(s):

Will documents be received in another name? F Yes F No

If yes, list name(s):

Date

Stamp

Here

1. Do you have a medical condition which in any wayimpairs or limits your ability to practice your

profession with reasonable skill and safety? If yes, please attach explanation. .......................................

F F

“Medical Condition” includes physiological, mental or psychological conditions or

disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments,

cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes,

intellectual disabilities, emotional or mental illness, specific learning disabilities, HIV disease,

tuberculosis, drug addiction, and alcoholism.

If you answered yes to question 1, explain:

1a. Howyour treatment has reduced or eliminated the limitations caused by your medical condition.

1b. Howyour field of practice, the setting or manner of practice has reduced or eliminated the

limitations caused by your medical condition.

Note: If you answered “yes” to question 1, the licensing authority will assess the nature,

severity, and the duration of the risks associated with the ongoing medical condition

and the ongoing treatment to determine whether your license should be restricted,

conditions imposed, or no license issued.

The licensing authority may require you to undergo one or more mental, physical or

Psychological examination(s). This would be at your own expense. Bysubmittingthis

Application, you give consent to such an examination(s). Youalso agree the

Examination report(s) may be provided to the licensing authority. You waive all claims

basedon confidentiality orprivileged communication.If you do not submitto a

Required examination(s) or provide the report(s) to the licensing authority,your

application maybe denied.

2. Do you currently use chemical substance(s) in any way which impair or limit your ability to

practice your profession with reasonable skill and safety? If yes, please explain. ...................................

F F

“Currently” means within the past two years.

“Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally.

3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or

frotteurism? ...............................................................................................................................................

F F

4. Are you currently engaged in the illegal use ofcontrolled substances? ...................................................

F F

“Currently” means within the past two years.

Illegal use ofcontrolled substances is the use of controlled substances (e.g., heroin, cocaine)

not obtained legally or taken according to the directions of a licensed health care practitioner.

Note: If you answer “yes” to any of the remaining questions, provide an explanation and

Certified copies of all judgments, decisions, orders, agreements and surrenders. The

department does criminal background checks on all applicants.

Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had

prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? ...F F

Note: If you answered “yes” to question5, you must send certified copies of all court

documents related to your criminal history with your application. If you do not

provide the documents, your application is incomplete and will not be considered.

To protect the public, the department considers criminal history. Acriminal history

maynot automatically bar you from obtaining a credential. However, failure to report

criminal history may result in extra cost to you and the application may be delayed

or denied.

DOH 667-001 July 2015 Page 2 of 4

2. Personal Data Questions

Yes No

6. Have you ever been found in any civil, administrative or criminal proceeding to have:

a. Possessed, used, prescribed for use, or distributed controlled substances or legend

drugs in any way other than for legitimate or therapeutic purposes? ...................................................

F F

b. Diverted controlled substances or legend drugs? ................................................................................

F F

c. Violated any drug law? .........................................................................................................................

F F

d. Prescribed controlled substances for yourself? ....................................................................................

F F

7. Have you ever been found in any proceeding to have violated any state or federal law or rule

regulating the practice of a health care profession? If “yes”, please attach an explanation and

provide copies of all judgments, decisions, and agreements? . ...............................................................

F F

8. Have you ever had any license, certificate, registration or other privilege to practice a health care

profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? ..............

F F

9. Have you ever surrendered a credential like those listed in number 8, in connection with or to

avoid action by a state, federal, or foreign authority? ...............................................................................

F F

10. Have you ever been named in any civil suit or suffered any civil judgment for incompetence,

negligence, or malpractice in connection with the practice of a health care profession? .........................

F F

11. Have you ever been disqualified from working with vulnerable persons by the Department of

Social and Health Services (DSHS)? .......................................................................................................

F F

DOH 667-001 July 2015 Page 3 of 4

2. Personal Data Questions (cont.)

Yes No

3. Other License, Certification, or Registration

List all states, including Washington, where credentials are or were held. Specifically list credentials granted as

temporary, reciprocity, exemption or similar with type, date, grantor, and if credential is current. Attach additional

completed pages if you need more space.

State/Jurisdiction

License Type

License

Number

Issue DateExpiration Date

LicenseMethod

Licensed

4. AIDS Education and Training Attestation

I certify I have completed the minimum of seven hours of education in the prevention, transmission, and

treatment ofAIDS. The education was through my professional education or through the completion of

DSHS required training for caregivers or staff employed in DDD Certified Residential Programs. This

includes the topics of etiology and epidemiology, testing and counseling, infectious control guidelines, clinical

manifestations and treatment, legal and ethical issues to include confidentiality, and the psychosocial issues

to include special population considerations.

I understand I must maintain records documenting said education for two years and be prepared to submit

those records to the department ifrequested. I understand if I provide any false information, my

certificationorregistrationmaybedenied,orifissued,suspendedorrevoked.

Applicant’s Initials Date

5. Applicant’s Attestation

I, ________________________________ , declare under penalty of perjury under the laws of the state of

Washington the following is true and correct:

• I am the person described and identified in this application.

•

I have read RCW 18.130.170

and RCW 18.130.180 of the Uniform Disciplinary Act.

• I have answered all questions truthfully and completely.

• The documentation provided in support ofmy application is accurate to the best ofmy

knowledge.

I understand the Department of Health may require more information before deciding on my application. The

department may independently check conviction records with state or federal databases.

I authorize the release of any files or records the department requires to process this application. This

includes information from all hospitals, educational or other organizations, my references, and past and present

employers and business and professional associates. It also includes information from federal, state, local or

foreign government agencies.

I understand I must inform the department ofany past, current or future criminal charges or

convictions. I will also inform the department of any physical or mental conditions that jeopardize my ability

to provide quality health care. Ifrequested, I will authorize my health providers to release to the department

information on my health, including mental health and any substance abuse treatment.

Dated ________________ _____________________________________________________ in

By: ________________________________________

(Original signature of applicant)

(mm/dd/yyyy)

(Print applicant name clearly)

DOH 667-001 July 2015 Page 4 of 4

(City, state)

Part 2

To be completed by the state commission/board/committee and returned to the Washington State

Department of Health at the address provided above.

License/Certification/Registration issued on _________________ Number____________________________

Applicant licensed by: Exam _______________Endorsement ________________________________ Waiver

Status of License/Certification/Registration:

Current

Not CurrentIf not, explain ________________

_______________________________________________________________________________________

Has license/certification/registration ever been encumbered in any way? (Revoked, suspended, surrendered,

restricted, placed on probationary status or under investigation.)

Yes

No If yes, explain ___________

_______________________________________________________________________________________

Signature _______________________________________________

Name/Title_______________________________________________

State ___________________________________________________

Part 1: Note to applicant

Complete part 1 Submit form(s) to all state commissions/boards/committees where you have ever

been licensed, certified, or registered.

Name __________________________________________________________________________________

I was licensed/certified/registered by the ______________________________ Commission/Board/Committee

under the name __________________________________________________________________________

My original license/certification/registration number is ____________________________________________

My Address is ___________________________________________________________________________

Signature of applicant _____________________________________________________________________

Out-of-State Credential Verification Form

State

(SEAL)

Nursing Assistant Credentialing

P.O. Box 47877

Olympia, WA 98504-7877

360-236-4700

DOH 667-038 July 2015

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DOH RCW/WAC and Online Website Link July 2015

RCW/WAC Links

Uniform Disciplinary Act, RCW 18.130

Administrative Procedure Act, RCW 34.05

Administrative Procedures and Requirements, WAC 246-12

Nursing Assistance Law, RCW 18.88

Nursing Assistance Rules, WAC 246-841

Online

AIDS Training Resources, Reference Page

Nursing Assistant Program, Web page

RCW/WAC and Online Website Links