Form 5506-NAR "Texas Nurse Aide Registry Employment Verification" - Texas

What Is Form 5506-NAR?

Form 5506-NAR, Texas Nurse Aide Registry Employment Verification, is a form that has to be completed by a nurse aide and their employer to verify employment. To remain on active status and to provide services in nursing facilities, nurse aides have to do such verifications at least every two years.

This form was released by the Texas Health and Human Services and the latest version was issued in on March 1, 2018. A fillable Form 5506-NAR (Employment Verification) is available for download below.

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Form 5506-NAR Instructions

The instructions for filling in Form 5506-NAR are the following:

  1. This form can be completed in blue ink only.
  2. Section 1 should be filled in by a nurse aide. Before completing the form, a nurse aid has to verify their information in the Credential Manager system. After registration, their identification number should be entered in the form.
  3. The applicant should outline their personal information in the table, including their name, address, Social Security number, and Certified Nurse Aide (CNA) number.
  4. The applicant should answer the questions below the table to verify the requirements for Nurse Aide Recertification.
  5. Signature of the applicant and the date should be provided.
  6. A photocopy of picture identification must be attached to the form.
  7. Section 2 should be filled in by the employer of the nurse aide.
  8. The employer has to provide information about their company and the working period of the nurse aide in this organization.
  9. The employer can add comments concerning nursing services performed by the indicated nurse aide or other important information on the space provided.
  10. The signature of the employer and the date should be indicated.
  11. The employer's signature has to be notarized at the bottom of this section and returned to the nurse aide.
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Download Form 5506-NAR "Texas Nurse Aide Registry Employment Verification" - Texas

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Form 5506-NAR
March 2018-E
Texas Nurse Aide Registry
Employment Verification
Please complete document in blue ink only.
Section 1. To be completed by Nurse Aide - Please read the following instructions before completing this form.
The Nurse Aide Registry has implemented a new online system called Credential Manager. Before completing this form, you are required to
verify your information in the new system at: https://i7lp.integral7.com/txna. Click on "Up For Renewal but Never Logged In" and complete
your registration. Once you have registered, please list your identification number here:
I.D. No.:
● Complete all information in Section 1 and sign to verify that the information provided is correct.
● Attach a legible photocopy of a picture identification that shows your birth date and the correct spelling of your name.
● Obtain employer verification (Section 2). Form must be mailed to: Texas Nurse Aide Registry, P.O. Box 149030, Mail Code E-414, Austin, TX
78714-9030. Faxes and copies will not be processed.
To verify your Certified Nurse Aide (CNA) number, use the following
link:
https://emr.dads.state.tx.us/DadsEMRWeb/.
Note:
A list of approved in-service education programs can be found at:
https://hhs.texas.gov/nar-cbts
or
https://hhs.texas.gov/nar-approved-
inservice
The Texas Nurse Aide Registry will return (without action) incomplete requests and requests without the required documents.
Name of Applicant (Last, First, Middle)
Maiden Name (if applicable)
Mailing Address (Street or P.O. Box)
City
State
ZIP Code
Daytime Area Code and Telephone No.
Social Security No.
Sex
Date of Birth (mm/dd/yyyy)
Email Address
Male
Female
CNA Certificate No.
Verification of requirements for Nurse Aide Recertification
Are you listed on the Employee Misconduct Registry (EMR) as unemployable?........................................................................
Yes
No
Have you been found to have a conviction of a criminal offense listed in Texas Health and Safety Code, §250.006? ..............
Yes
No
If yes, give date of conviction.
Have you completed 24 hours of in-service education in the past two years?.............................................................................
Yes
No
Note: In-service education requirements are subject to audit. Be prepared to submit in-service certificates if contacted by Texas Health and
Human Services Commission (HHSC).
Date
Signature – Nurse Aide
Section 2. To be completed by the Employer - Instructions:
● This section must be completed by the facility program director, official keeper of records or actual employer.
● Notarize employer signature at the bottom of this section and return to nurse aide.
Employer Name or Company Name
Daytime Area Code and Telephone No.
Mailing Address (Street or P.O. Box)
City
State
ZIP Code
I certify that the individual named above is/was employed by me as a nurse aide and performed nursing/nursing-related services
from (mm/dd/yyyy)
to (mm/dd/yyyy)
and that I am not aware of any disqualifying misconduct.
Comments:
Date
Signature – Employer
Sworn and subscribed to me on this
day of
, 20
,
in
County, in the state of
.
Signature – Notary Public
Place Notary Seal or Stamp Here
Date Commission Expires
Tampering with or attempting to falsify a government record as such a nurse aide certificate is a third-degree felony punishable by up to 10 years in prison and a $10,000
fine.
Form 5506-NAR
March 2018-E
Texas Nurse Aide Registry
Employment Verification
Please complete document in blue ink only.
Section 1. To be completed by Nurse Aide - Please read the following instructions before completing this form.
The Nurse Aide Registry has implemented a new online system called Credential Manager. Before completing this form, you are required to
verify your information in the new system at: https://i7lp.integral7.com/txna. Click on "Up For Renewal but Never Logged In" and complete
your registration. Once you have registered, please list your identification number here:
I.D. No.:
● Complete all information in Section 1 and sign to verify that the information provided is correct.
● Attach a legible photocopy of a picture identification that shows your birth date and the correct spelling of your name.
● Obtain employer verification (Section 2). Form must be mailed to: Texas Nurse Aide Registry, P.O. Box 149030, Mail Code E-414, Austin, TX
78714-9030. Faxes and copies will not be processed.
To verify your Certified Nurse Aide (CNA) number, use the following
link:
https://emr.dads.state.tx.us/DadsEMRWeb/.
Note:
A list of approved in-service education programs can be found at:
https://hhs.texas.gov/nar-cbts
or
https://hhs.texas.gov/nar-approved-
inservice
The Texas Nurse Aide Registry will return (without action) incomplete requests and requests without the required documents.
Name of Applicant (Last, First, Middle)
Maiden Name (if applicable)
Mailing Address (Street or P.O. Box)
City
State
ZIP Code
Daytime Area Code and Telephone No.
Social Security No.
Sex
Date of Birth (mm/dd/yyyy)
Email Address
Male
Female
CNA Certificate No.
Verification of requirements for Nurse Aide Recertification
Are you listed on the Employee Misconduct Registry (EMR) as unemployable?........................................................................
Yes
No
Have you been found to have a conviction of a criminal offense listed in Texas Health and Safety Code, §250.006? ..............
Yes
No
If yes, give date of conviction.
Have you completed 24 hours of in-service education in the past two years?.............................................................................
Yes
No
Note: In-service education requirements are subject to audit. Be prepared to submit in-service certificates if contacted by Texas Health and
Human Services Commission (HHSC).
Date
Signature – Nurse Aide
Section 2. To be completed by the Employer - Instructions:
● This section must be completed by the facility program director, official keeper of records or actual employer.
● Notarize employer signature at the bottom of this section and return to nurse aide.
Employer Name or Company Name
Daytime Area Code and Telephone No.
Mailing Address (Street or P.O. Box)
City
State
ZIP Code
I certify that the individual named above is/was employed by me as a nurse aide and performed nursing/nursing-related services
from (mm/dd/yyyy)
to (mm/dd/yyyy)
and that I am not aware of any disqualifying misconduct.
Comments:
Date
Signature – Employer
Sworn and subscribed to me on this
day of
, 20
,
in
County, in the state of
.
Signature – Notary Public
Place Notary Seal or Stamp Here
Date Commission Expires
Tampering with or attempting to falsify a government record as such a nurse aide certificate is a third-degree felony punishable by up to 10 years in prison and a $10,000
fine.
Form 5506-NAR
Page 2 / 3-2018-E
Address:
● Did you enclose a legible photocopy of your picture ID?
● Did you sign Section 1?
● Did your employer notarize his/her signature in Section 2?
Did you know?
● You can verify certificate status by using the following link:
https://emr.dads.state.tx.us/DadsEMRWeb/.
● You can download forms from our website:
https://hhs.texas.gov/doing-business-hhs/licensing-credentialing-regulation/
nurse-aide-registry/nar-forms.
Texas Nurse Aide Registry
Mail Code E-414
P.O. Box 149030
Austin, Texas 78714-9030
With a few exceptions, you have the right to request and be informed about the information that the Texas Health and Human Services
Commission (HHSC) obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask
HHSC to correct information that is determined to be incorrect (Government Code, Sections 552.021, 552.023, 559.004). To find out about
your information and your right to request correction, please contact the Nurse Aide Registry at 512-438-2050.
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