Article Structure
The Wisconsin Nurse Aide Renewal form is essential for maintaining your eligibility to work in specific health care settings. To complete this form, applicants must provide detailed personal information, including their Social Security number, legal name, and current mailing address. It is crucial to indicate any changes to your name and submit relevant documentation if necessary. The form also requires verification of nursing or nursing-related work conducted under the supervision of a registered nurse (RN) or licensed practical nurse (LPN) within the last twenty-four months. This is vital as failure to report recent employment could hinder your ability to work in federally certified facilities. Health care employers must fill out a section that confirms the nurse aide's employment, ensuring they have met the required hours of service. Once completed, the form must be mailed correctly to avoid delays, and applicants should allow two weeks for processing. If you are on active military duty, special provisions apply for renewing your certification. For any questions regarding the process, contacting the Wisconsin Nurse Aide Registry is recommended.
Wi Nurse Aide Renewal Example
Wisconsin Nurse Aide Program
NURSE AIDE REGISTRY RENEWAL FORM INSTRUCTIONS
Federal and state regulations require that you performed nursing or
Allow two (2) weeks for processing your completed form. To verify the processing status of your Renewal form, you may check your status on the Wisconsin Nurse Aide Registry website at http://www.pearsonvue.com or call the Wisconsin Nurse Aide Registry at (877)
If you are on active military duty when your certification expires, or if you are the civilian spouse of a service member on active military duty when your certification expires and are unable to practice under your nurse aide certification during your spouse’s active military duty, you may be eligible for an extension of your certification for 180 days after the date of discharge from active duty and to renew your certification to the next biennium without completing the required
SECTION I — COMPLETED BY THE NURSE AIDE
1.Social Security number: Enter your Social Security number or previously assigned Nurse Aide Registry identification number. Providing your Social Security number is voluntary. Social Security numbers are used to determine nurse aide employment eligibility for prospective employers.
2.Gender: Check the appropriate box, female or male.
3.Date of Birth: Enter your month, date, and year of birth.
4.Current Legal Name: Check “yes” if your name has changed. Enter your current full name (last, first, and middle initial). Do NOT use nicknames (for example, enter “William” instead of “Bill”, “Jennifer” instead of “Jenny”, “Richard” instead of “Dick”, etc.).
5.Previous Name (if applicable): Enter your previous name if any change in your last name, first name, or middle initial has oc- curred (for example, maiden name, name change, etc.).
To change or correct your name or Social Security number, attach a copy of a document that proves the correct informa- tion (for example, driver’s license, Social Security card, etc.).
6.Current Mailing Address: Enter your current address (street, P.O. box, city, state, and ZIP).
7.Home/Work Telephone Number: Enter your current home and work telephone numbers.
8.Nurse Aide Signature: Sign and date the form.
SECTION II — COMPLETED BY THE HEALTH CARE EMPLOYER
9.Enter the individual’s starting date of employment at your facility.
10.Check “Yes” or “No” if the nurse aide has provided nurse aide services for at least eight (8) hours for pay during the
01:Clinics
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03:Emergency Centers
04:Home Health Agencies
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Hospices |
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Nursing Homes |
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Hospitals |
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County or School Nurse |
07:Intermediate Care Facilities for Persons with Mental Retardation (ICFs/MR)
11.Current or most recent health care employer: Enter the name, type of health care facility, full address, and telephone number of the facility. Indicate whether the nurse aide is your direct employee or a contracted pool aide.
12.Signature of facility representative: A representative of the health care facility must sign his/her name and date the form, verifying that an RN or LPN is supervising the nurse aide’s
Mail the COMPLETED form to:
Pearson VUE – Wisconsin Nurse Aide Registry
PO Box 13785
Philadelphia, PA
Incomplete, unsigned, or illegible forms will not be processed. If you have any questions about completing the Nurse Aide Registry Renewal Form, please contact the Registry at (877)
Wisconsin Nurse Aide Program
NURSE AIDE REGISTRY RENEWAL FORM
Before completing this form, please carefully read the instructions on the reverse side.
If you are on active military duty when your certification expires or are the civilian spouse of a service member on active military duty when your certification expires, do not complete this form. Instead please contact the Office of Caregiver Quality at (608)
SECTION I – COMPLETED BY NURSE AIDE (Please type or print neatly in black ink)
1. Social Security Number: ■■■- ■■- ■■■■
2. Gender: |
■ Female |
■ Male |
3. Date of Birth Date: ■■- ■■- ■■■■
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MONTH |
DAY |
YEAR |
4. Name Change? |
■ Yes |
■ No |
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CURRENT Full Name: DO NOT USE NICKNAMES
To change or correct your name or Social Security number, attach a copy of a document that proves the correct information (for example, driver’s license, Social Security card, etc.).
■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■
LAST |
FIRST |
MI |
5.PREVIOUS Name (if applicable):
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LAST |
FIRST |
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MI |
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6. |
CURRENT Mailing Address: |
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■■■■■■ ■■■■■■ |
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STREET (number and name) |
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APARTMENT NUMBER |
PO BOX |
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■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■ |
■■■■■ |
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CITY |
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STATE |
ZIP CODE |
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7. |
Home Phone Number: ■■■- ■■■- ■■■■ Work Phone Number: ■■■- ■■■- ■■■■ |
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AREA CODE |
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AREA CODE |
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8. |
Signature – Nurse Aide: |
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SIGNATURE OF APPLICANT |
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DATE SIGNED |
■CHECK HERE IF YOU DO NOT WISH TO DISCLOSE YOUR NAME AND ADDRESS ON LISTS THAT ARE FURNISHED BY PEARSON VUE UPON REQUEST.
SECTION II – COMPLETED BY CURRENT OR MOST RECENT HEALTH CARE EMPLOYER
9. |
Enter the nurse aide’s START DATE at your facility: ■■- ■■- ■■■■ |
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MONTH DAY |
YEAR |
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10. |
Has the nurse aide provided nurse aide services for at least eight (8) hours for pay during the |
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before their registration expiration date? |
■ Yes |
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No |
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Enter the MOST RECENT DATE the person worked as an aide |
■■- ■■- |
■■■■ |
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providing a |
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MONTH |
DAY |
YEAR |
11.Name of Health Care Facility ■■■■■■■■■■■■■■■■■■■■■■■■■■■■
Type of Health Care Facility (enter |
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Direct Employee? ■ Yes ■ No |
Staffing or Pool Aide? ■ Yes ■ No |
12. Signature – Health Care Facility Representative:
I verify that the
SIGNATURE OF HEALTH CARE FACILITY REPRESENTATIVE |
DATE SIGNED |
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PRINTED NAME |
TITLE |
This form may not be processed if the form is received by fax, or is incomplete, unsigned, or illegible.
PLEASE PRINT NEATLY IN BLACK INK. Then SIGN the form and MAIL it to:
Pearson VUE – Wisconsin Nurse Aide Registry, PO Box 13785, Philadelphia, PA
Copyright © 2012 Pearson Education, Inc., or its affiliate(s). All Rights Reserved. Pubs_orders@Pearson.com |
Stock# 075005 7/12 |
Form Characteristics
| Fact Name | Description |
|---|---|
| Eligibility Requirements | To renew your nurse aide certification, you must have performed nursing services for pay, under the supervision of an RN or LPN, within the last 24 months. |
| Processing Time | Your completed form will take approximately two weeks to process. Checking the status can be done online or by calling the provided number. |
| Military Extension | If you are on active military duty when your certification expires, you might qualify for a 180-day extension post-discharge, allowing for renewal without re-testing. |
| Governing Laws | This form adheres to federal and state regulations, including those outlined in the Wisconsin Administrative Code Chapter N 2, regarding nurse aide certifications. |
Guidelines on Utilizing Wi Nurse Aide Renewal
Once you have gathered the necessary information, you can begin filling out the Wisconsin Nurse Aide Renewal Form. Completing this form accurately is essential in maintaining your eligibility to work in federally certified facilities. Below are the steps you need to follow to ensure your form is filled out correctly.
- Social Security Number: Enter your Social Security number or previously assigned Nurse Aide Registry identification number. Providing this number is optional but helps employers verify your employment eligibility.
- Gender: Check either the female or male box.
- Date of Birth: Enter your birth date in the format: month, day, year.
- Current Legal Name: Indicate if your name has changed. Provide your full name (last, first, middle initial) without using nicknames.
- Previous Name: If applicable, enter your previous name. Attach documents that prove any name changes.
- Current Mailing Address: Fill in your current mailing address including street, city, state, and ZIP code.
- Home/Work Telephone Number: Provide both your home and work phone numbers.
- Nurse Aide Signature: Sign and date the form here.
- Starting Date of Employment: The health care employer must enter your start date at their facility.
- Nurse Aide Services: The employer must check "Yes" or "No" to indicate whether you provided nursing services for at least eight hours for pay in the past twenty-four months. If yes, they should enter the date of your most recent work.
- Health Care Employer Details: Enter the name and contact details of the health care facility where you worked, including whether you are a direct employee or a staffing pool aide.
- Facility Representative Signature: A facility representative must sign and date the form, verifying that you have worked under the supervision of an RN or LPN.
After completing the form, ensure it is signed and then mail it to Pearson VUE at the provided address. Give the processing team approximately two weeks to handle your request. If any part of the form is incomplete, it will not be processed, so double-check all entries.
What You Should Know About This Form
What is the purpose of the Wisconsin Nurse Aide Renewal form?
The Wisconsin Nurse Aide Renewal form is required in order to report your employment history as a nurse aide. Its completion helps maintain your eligibility to work in federally certified healthcare facilities. Without submitting this form, you may jeopardize your ability to secure employment in such settings.
How often do I need to complete the renewal form?
This form must be completed every two years. The renewal process involves verifying that you have performed nursing or nursing-related services for a minimum of eight hours during the previous twenty-four months under the supervision of a registered nurse (RN) or licensed practical nurse (LPN).
What information is required on the renewal form?
You will need to provide personal details including your Social Security number, date of birth, and current legal name. If your name has changed, you must also include your previous name. Additionally, both your current mailing address and contact numbers need to be listed. Employment information, such as the name of your healthcare facility and supervisor details, is also required.
Will my personal information remain confidential?
The personal information you provide will only be used for the purpose of updating your Nurse Aide Registry records. It is essential to ensure accurate identification for administrative purposes. Confidentiality is maintained and only authorized personnel have access to this information.
What if I am on active military duty when my certification expires?
If you are on active military duty at the time of your certification expiration, or if you are a civilian spouse of a service member, you may qualify for a 180-day extension of certification. During this time, you can renew your certification for the next biennium without undergoing the required re-testing.
How long does it take to process the renewal form?
Once you have submitted the completed form, you should allow a processing time of approximately two weeks. During this period, it is advisable to refrain from assuming your renewal has been accepted until you receive confirmation.
How can I verify the status of my renewal form?
To verify the processing status of your form, you can visit the Wisconsin Nurse Aide Registry website or call the provided phone number. Checking your status online is a quick and efficient way to find updates on your application.
What happens if my renewal form is incomplete or inaccurate?
An incomplete, unsigned, or illegible renewal form will not be processed. It is crucial to ensure that all fields are filled out correctly and that your signature is included. Double-checking your information before submission can prevent delays in processing.
Who should sign the form on behalf of the healthcare employer?
The health care facility representative who supervises your work as a nurse aide must sign the form. This signature verifies that you have provided nursing-related services under the guidance of an RN or LPN. If you work for a temporary agency, a representative from the health care facility must still complete this section.
Common mistakes
Filling out the Wisconsin Nurse Aide Renewal form can seem straightforward, but many individuals make errors that can lead to processing delays or complications with their certification. One of the most common mistakes involves the Social Security number section. Applicants sometimes fail to provide the correct number or mistakenly use a previously assigned Nurse Aide Registry identification number instead. It is crucial to ensure that the number entered is accurate and corresponds to the individual's most current records.
Another frequent error occurs when applicants attempt to use nicknames on the form. In the section for the current legal name, it is essential to provide the full legal name without any variations. For instance, using "Dave" instead of "David" can lead to discrepancies that may affect the processing of the application.
People also often overlook completing the Previous Name section, especially if there has been a name change, such as a maiden name. This oversight can result in confusion in identifying the individual’s records. Attaching supporting documentation, like a marriage certificate or court order, can also be neglected, which is necessary to verify any name changes.
The section that asks for the Current Mailing Address is another area where mistakes are regularly made. Applicants may forget to include their apartment number or provide outdated information. Failure to provide accurate contact information can hinder effective communication regarding the application status.
Additionally, the Date of Birth field is sometimes filled out incorrectly. It is important to enter the month, day, and year in the correct format. A typographical error here could lead to rejections from the Registry due to mismatches with identification records.
Some applicants may also forget to sign and date the form, which is a critical requirement. An unsigned form will not be processed, and this simple oversight can lead to significant delays in renewing certification. Make sure to double-check for a signature before submission.
In the employer section, failure to provide complete and current details about the health care employer is another common mistake. Missing information such as the full address or lack of clarity about whether the nurse aide is a direct employee or a staffing agency employee can complicate the verification process.
Lastly, many people fail to check their application for legibility before mailing it. Forms that are illegible will not be processed. It is advised to use black ink and print neatly, ensuring that all information is easy to read. Any of these mistakes can lead to delays or rejection of the application, so extra care should be taken during the submission process.
Documents used along the form
The Wisconsin Nurse Aide Renewal Form is essential for maintaining your eligibility to work in federally certified facilities. Several other forms and documents often accompany this renewal form to ensure all necessary information and requirements are met. Here’s an overview of these documents:
- Employment Verification Form: This document confirms the nurse aide’s employment history, detailing shifts worked under the supervision of an RN or LPN.
- Background Check Authorization: Required for new applicants and renewals, this form authorizes the completion of a criminal background check.
- Name Change Documentation: If applicable, provide documents such as a marriage certificate or court order to validate any name changes since the last renewal.
- Proof of Education: Evidence of completion of a state-approved nursing aide training program may be necessary if the aide is renewing their certification after an extended gap in employment.
- Military Service Verification: For those on active military duty or spouses of service members, this documentation substantiates claims for certification extension.
- Training and Competency Evaluation Program (TCEP) Completion Form: This form confirms that the nurse aide has met training and competency standards as required by the state.
- Supervisory Verification Report: A health care facility representative must complete this report, verifying that the aide has worked the required number of hours under supervision.
- Reinstatement Application: Applicable for those whose certifications have lapsed; this application initiates the process to reinstate Nurse Aide statuses.
- Current Contact Information Update: Use this form to provide up-to-date contact information for communication regarding the Renewal process.
Submitting the appropriate documents along with the Wisconsin Nurse Aide Renewal Form is critical for ensuring compliance and smooth processing. Review the requirements thoroughly to avoid delays in your certification renewal.
Similar forms
- Certification Renewal Application: Similar to the Wi Nurse Aide Renewal form, this document requires applicants to demonstrate recent work in their field to maintain certification validity. Both forms focus on employment history and require proof of current qualifications.
- Employment Verification Form: This document is used to confirm an employee’s work history. Just like the Nurse Aide Renewal form, it gathers detailed information about employment dates and the nature of the work performed.
- Continuing Education Verification Form: This form is essential for professionals needing to show ongoing education credits. It parallels the Nurse Aide Renewal form by tracking activity and ensuring compliance with state regulations to maintain licensure.
- Professional License Renewal Form: Like the Nurse Aide Renewal form, it encompasses personal and employment information to gauge eligibility for license renewal. It also mandates proof of adequate practice within a set timeframe.
- Temporary Permit Application: This document allows professionals to practice temporarily while awaiting permanent certification. Similar to the Nurse Aide form, it includes personal verification and documentation of recent work experience to validate the request.
- Background Check Authorization Form: This form is necessary for verifying candidates’ eligibility to work in healthcare. It correlates with the Nurse Aide Renewal form in collecting personal data that confirms the applicant's integrity and suitability for employment.
- Health Care Provider Credentialing Application: This document is utilized by healthcare facilities to verify qualifications of potential employees. Its structure mirrors the Nurse Aide Renewal form in requiring documentation of employment history and proof of applicable skills and training.
Dos and Don'ts
Filling out the Wisconsin Nurse Aide Renewal form is a critical step to maintaining your eligibility to work. Here are some essential do’s and don’ts to keep in mind:
- Do check the specific eligibility requirements before you begin, ensuring you comply with employment history regulations.
- Do provide accurate and complete information, especially your Social Security number, current legal name, and recent work details.
- Do use your full legal name without any nicknames—this is crucial for proper identification.
- Do sign and date the form. An unsigned application will not be processed, so double-check this step.
- Don’t leave any sections blank. Incomplete forms will be rejected, so ensure every required space is filled.
- Don’t attempt to abbreviate your name or provide alternative names; the Registry requires full names for verification.
- Don’t forget to include a contact number for any follow-up inquiries. This can help in case there are issues with processing.
- Don’t submit the form via fax. Mail it to the specified address to avoid delays in your renewal process.
By adhering to these guidelines, you can help facilitate a smooth renewal process. Timely submission is essential, so take action as soon as possible!
Misconceptions
Here are some common misconceptions about the Wisconsin Nurse Aide Renewal Form:
- It is only for those who have let their certification expire. The renewal form is meant for those who wish to maintain their certification, even if it is not currently expired.
- Filing the form is the only requirement to remain certified. Individuals must have performed nursing-related services for pay under the supervision of an RN or LPN in the past twenty-four months as part of the renewal process.
- You must disclose your Social Security number. Providing your Social Security number is voluntary, although it can help employers verify eligibility.
- All jobs qualify for the renewal. Only employment in recognized nursing-related service settings counts toward the renewal requirement.
- The form can be submitted electronically. The completed form must be mailed and cannot be sent by fax or email.
- Incomplete forms may still be processed. Forms that are incomplete, unsigned, or illegible will not be processed.
- Active military duty automatically disqualifies you from renewal. Active military personnel and their civilian spouses may qualify for a 180-day extension if specific conditions are met.
- Processing the form takes a short time. It can take up to two weeks for the form to be processed, so it’s important to plan accordingly.
Key takeaways
Here are essential points to consider when filling out and using the Wisconsin Nurse Aide Renewal form:
- Employment Requirement: You must have worked for pay in a nursing or nursing-related position under the supervision of an RN or LPN within the last 24 months.
- Update Your Information: Ensure all personal information is accurate, including your current legal name, address, and contact details.
- Social Security Number: While it's voluntary to provide your Social Security number, doing so helps confirm your employment eligibility.
- Signature Requirement: You must sign and date the form. A healthcare facility representative must also sign to verify your employment.
- Processing Time: After mailing your completed form, allow up to two weeks for processing. You can check your status online or call the Registry.
- Extensions for Military Personnel: If you are on active military duty or the spouse of someone on active duty, you may qualify for a 180-day extension of your certification.
- Incomplete Forms: Forms that are incomplete, unsigned, or illegible will not be processed. Make sure to follow all instructions carefully.
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