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Fill Out Your South Carolina Nurse Aide Form

The South Carolina Nurse Aide form is an essential document for individuals seeking to register as nurse aides in the state. This form ensures that applicants meet the specific eligibility requirements necessary for listing on the South Carolina Nurse Aide I Registry. If you are ready to begin this important process, please fill out the form by clicking the button below.

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Fill Out Your South Carolina Nurse Aide Form

Article Structure

The South Carolina Nurse Aide form plays a crucial role in ensuring compliance with the regulations surrounding the nursing aide profession. This comprehensive document is part of the reciprocity application process for individuals seeking to be listed on the North Carolina Nurse Aide I Registry. The form outlines essential eligibility requirements, guiding applicants through various sections that collect personal and professional information. Key components include an assessment of prior nursing experience, submission of personal identification, documentation of training, and verification of good standing on existing state registries. Applicants must demonstrate they have maintained active status in another state, have fulfilled the social security and identification prerequisites, and have completed the requisite training and competency evaluation. Sections dedicated to employment history and types of nursing-related tasks performed facilitate this process, requiring past employers’ details and other pertinent information. Incomplete submissions can result in delays, so applicants are strongly advised to follow the instructions meticulously. Adhering to these guidelines not only streamlines the application process but also contributes significantly to maintaining standardization and accountability within the nursing aide profession.

South Carolina Nurse Aide Example

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

Get South Carolina Nurse Aide PDF Form

Form Characteristics

Fact Name	Details
Eligibility Requirements	To be listed on the Nurse Aide I Registry, you must meet specific criteria, including active status on another state registry and no pending abusive findings.
Documentation Needed	Applicants must submit a completed application, including all required pages and supportive documentation to ensure the application is processed without delays.
Governing Law	The Nurse Aide I Registry in South Carolina is governed by 42 CFR 483.152 and 42 CFR 483.154, ensuring compliance with federal guidelines.
Application Review Timeline	The Department is required to review applications within 10 business days from the date they are received.
Identification Requirements	Applicants must provide a social security card and government-issued ID, ensuring names match on all documents to avoid delays.

Guidelines on Utilizing South Carolina Nurse Aide

Once you've gathered all the necessary information and documents, you're ready to begin filling out the South Carolina Nurse Aide form. Completing this form correctly ensures that your application is processed quickly and without any hitches. Make sure you have blue or black ink handy and be prepared to submit all pages of the application along with any required supporting documents.

Confirm Eligibility: Review the eligibility criteria in Part 1. Ensure you meet all five requirements before proceeding.
Personal Information: In Part 2, fill in your legal name, gender, social security number, date of birth, and contact information. Include any prior names if applicable.
Training & Evaluation Program: Answer the questions in Part 3 about your state-approved nurse aide training and competency evaluation program.
Nurse Aide Registries: In Part 4, list all states where you have an active or expired nurse aide I registry. Provide the necessary details, including original issue and expiration dates, and verify your status.
Employment Type: Select your employment type from the options in Part 5 where you performed nursing or nursing-related tasks in the past two years.
Employment History: Provide details about your employment where you served as a nurse aide in Part 6, including the name of the employer, location, and dates of employment.
Review & Submit: Double-check all sections of the form for completeness and accuracy. Ensure you attach any required documentation. Submit your application either by mail to the provided address or via fax to the specified number.

What You Should Know About This Form

What is the purpose of the South Carolina Nurse Aide form?

The South Carolina Nurse Aide form is used to apply for reciprocity to be listed on the North Carolina Nurse Aide I Registry. It helps confirm that applicants meet specific eligibility requirements, such as being active on another state's registry and having relevant work experience.

What are the eligibility requirements to complete the Nurse Aide form?

To be eligible, you must meet five criteria: be active and in good standing on another state's nurse aide registry, have no abuse or neglect findings, have worked as a nurse aide for at least eight hours in the last two years, provide matching identification documents, and have completed an approved nurse aide training program.

How should I submit my completed Nurse Aide application?

You can submit your completed Nurse Aide application by either mail or fax. If mailing, send it to 2709 Mail Service Center, Raleigh, NC 27699-2709. For faxing, use the number 919-733-9764. Remember to use black or blue ink, as other colors are not legible for fax transmission.

What happens if I submit an incomplete application?

Submitting an incomplete application means it will not be processed. It's crucial to fill out all sections of the form and provide all necessary documentation to avoid delays or denial of your application.

Can I submit more than one application at a time?

Generally, you should not submit more than one application unless instructed to do so by the Division of Health Service Regulation (DHSR). This helps to simplify the processing of applications and reduce confusion.

What if my name has changed since my last registry application?

If your name has changed, the names on your social security card, government-issued ID, and nurse aide registry must match. You will need to submit documentation that verifies your name changes, such as a marriage license or a divorce decree, if there is a discrepancy.

Common mistakes

When applicants fill out the South Carolina Nurse Aide form, several common mistakes can lead to delays or denials in processing. Understanding these pitfalls can help ensure a smoother application process.

One significant mistake occurs when individuals fail to check the eligibility criteria thoroughly before beginning their application. For example, applicants may not realize they need to be listed as active and in good standing on another state's nurse aide registry. If an applicant holds a temporary listing instead, they will not qualify for reciprocity. Neglecting to verify this information beforehand can result in wasted time and resources.

Another frequent error involves incomplete applications. The instructions clearly state that all pages of the application must be completed and submitted. Leaving any part blank, even if it seems unimportant, can lead to an application being considered incomplete. As a consequence, the application will not be processed, which can cause significant delays in obtaining certification.

Using an ink color other than black or blue is another mistake that applicants may overlook. The form explicitly instructs individuals to use only black or blue ink, as other colors may not be readable via fax. Submitting a form filled out in a different color can lead to logistical issues that further hinder the application process.

Many applicants also overlook the requirement for matching names across various documents. The instructions emphasize that the name on the social security card, government-issued ID, and the nurse aide registry must all match. If there is any discrepancy, applicants must submit documentation that verifies their name change, such as a marriage license or divorce decree. Failing to do this can result in a denial of the application.

Additionally, applicants often forget to include required supportive documentation alongside the application form. For instance, if individuals have been employed in more than one state, they must provide documentation verifying that each registry listing is active and in good standing. Failing to submit this documentation may result in additional requests for paperwork, thereby delaying the entire process.

Lastly, many individuals do not answer all questions accurately or completely, especially those regarding their prior employment and military service. Inaccurate information can lead to a perception of dishonesty or might raise concerns during the review process. Providing truthful and detailed responses is crucial to avoid complications or questions about eligibility.

Documents used along the form

Alongside the South Carolina Nurse Aide form, several other important documents and forms may be required for individuals seeking to become a certified nurse aide. Each of these documents plays a vital role in verifying qualifications, ensuring compliance with state regulations, and facilitating smooth processing of applications. Understanding these forms can help applicants prepare effectively and avoid delays.

Nurse Aide Training Completion Certificate: This certificate verifies that the applicant has successfully completed a state-approved nurse aide training program. It is essential as proof of educational requirements.
Competency Evaluation Results: This document details the results of the competency exam that a nurse aide must pass. It serves as proof that the candidate has demonstrated the necessary skills and knowledge in the field.
Background Check Results: A criminal background check is often required to ensure the safety of patients. This document confirms that the individual has no disqualifying offenses that might prevent them from working in healthcare.
Proof of Employment: Documentation such as pay stubs or employer letters can be necessary to demonstrate prior employment as a nurse aide. This helps verify the experience needed for registry eligibility.
Social Security Card: A copy of the applicant’s social security card is needed for identification purposes and to verify eligibility for work in the United States.
Government-Issued Photo ID: A valid state-issued ID or driver’s license is required to confirm identity and match the name on other documents, crucial for processing applications.
Name Change Documentation: If an applicant’s name differs from that on their social security card or ID, they must provide documentation such as a marriage certificate or court order to verify the name change.
Nurse Aide Registry Verification Forms: Individuals with prior certifications need to provide forms verifying their status on other states' nurse aide registries to facilitate reciprocity.

Collectively, these documents and forms support the application process for nurse aides in South Carolina. Being well-prepared with these items can significantly smooth the way toward achieving certification and gaining access to invaluable career opportunities in healthcare.

Similar forms

North Carolina Nurse Aide I Application: Like the South Carolina Nurse Aide form, this application requires proof of good standing on other registries, documentation of training, and identification with matching names. Both forms also emphasize the importance of accurate and thorough completion.
Medicare Certification Forms: These documents, similar to the South Carolina Nurse Aide form, involve submission of specific eligibility documentation and provide a structured process for healthcare professionals to prove their credentials and maintain compliance.
Registered Nurse Licensing Application: This application is similar as it requires proof of previous education and background checks, as well as verification of good standing from other licensing bodies. Both applications follow a precise format that must be adhered to for successful submission.
Certified Nursing Assistant (CNA) Renewal Application: In both situations, applicants must provide evidence of prior training and experience, along with a clear identification process. Each form reflects the need for confirmation that the applicant remains fit for practice.
State Health Department Credentialing Applications: Like the South Carolina form, these applications require comprehensive background information and completion of specific state-approved training programs. Each aims to ensure that applicants are qualified and meet health and safety standards.
Home Health Aide Registration Forms: These forms share a similar structure, requiring proof of training and personal identification. Both documents must be filled out accurately to support the registration process for caregivers in home-based care settings.

Dos and Don'ts

Things You Should Do:

Review the eligibility requirements carefully before filling out the application.
Complete all pages of the application clearly, using black or blue ink only.
Provide accurate and matching information on your Social Security card and government-issued ID.
Submit the application along with any required verification documentation to avoid delays.

Things You Shouldn't Do:

Do not submit an application that is incomplete or contains errors.
Do not use any ink colors other than black or blue, as they may not be readable.
Do not provide more than one application unless explicitly instructed by DHSR.
Do not hide any pending findings related to abuse or neglect on your application.

Misconceptions

Misconception 1: Submitting multiple applications increases the chances of approval.

Submitting more than one application without instruction from the Department of Health Service Regulation (DHSR) could lead to confusion and delays. Only one application should be submitted unless specifically directed otherwise.

Misconception 2: All types of employment qualify for reciprocity.

Not all employment qualifies. Work as a private duty nurse aide does not meet the eligibility requirements. Only positions where nursing or nursing-related tasks were delegated and supervised by a Registered Nurse count toward eligibility.

Misconception 3: Name discrepancies do not matter.

The name on your social security card and identification must match exactly. If there are discrepancies, documentation proving your name change must be provided. Failure to do so can lead to application rejection.

Misconception 4: An expired certification is sufficient for application.

An active certification is necessary for reciprocity. If your certification has expired, you must ensure you meet all other eligibility criteria and provide a current, active status from another state registry.

Key takeaways

Key Takeaways for Filling Out the South Carolina Nurse Aide Form:

Eligibility is a priority; ensure you meet all five listed criteria before starting the application.
Complete all pages of the application (1 through 6) accurately and legibly. Incomplete applications will not be processed.
Use only black or blue ink; other colors may not be readable when faxed.
Your application should be submitted via mail or fax using the provided addresses and phone number.
Names on your social security card, identification, and nurse aide registry must match precisely.
Provide supporting documentation for any name changes if the names do not match.
Be prepared to submit verification of your active status on any state nurse aide registries you are part of.
Private duty employment does not qualify for the reciprocity eligibility requirement.

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