Nurse Aide Evaluator OBRA COMPLIANCE INFORMATION SHEET *Denotes required information Requirements: 1. Must have one year of registered nurse experience. 2. Must have at least one year of that RN experience caring for the elderly and/or chronically ill of any age. 3. Must have a current RN license in good standing. 4. Must be willing to complete a training and onboarding process before testing can start. STATES FOR APPLICATION *Denotes required information Please select up to three States for which you would like to apply to become an approved Nurse Aide Evaluator: State Requested 1 * State Requested 2 State Requested 3 ** Please Select ** Alabama Colorado Delaware District of Columbia Florida Georgia Idaho Louisiana Maine Maryland Massachusetts Mississippi Nevada New Jersey New York North Carolina Ohio Pennsylvania South Carolina Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ** Please Select ** Alabama Alaska Arizona Arkansas California Colorado Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Nevada New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania South Carolina South Dakota Tennessee Texas Vermont Virginia Washington West Virginia Wisconsin Wyoming ** Please Select ** Alabama Arizona Arkansas California Colorado Delaware District of Columbia Florida Georgia Hawaii Idaho Iowa Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania South Carolina Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming GENERAL INFORMATION Username* Password*     Last Name* First Name* MI Social Security Number*         Street Address* City* State* Zip*     ** Please Select ** Alabama Arkansas Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Louisiana Maine Maryland Massachusetts Minnesota Mississippi Nevada New Hampshire New Jersey New York None North Carolina Ohio Oregon Pennsylvania South Carolina Tennessee Texas Vermont Virginia Washington West Virginia Wisconsin Wyoming   Home Phone Work Phone Mobile Phone* Availability Date       Email Address*   REGISTERED NURSE LICENSES Primary State* Number* Expiration Date* ** Please Select ** Alabama Alaska Arkansas Colorado Delaware District of Columbia Florida Georgia Idaho Louisiana Maine Maryland Massachusetts Michigan Mississippi Nevada New Jersey New York North Carolina Ohio Pennsylvania South Carolina Tennessee Texas Vermont Virginia Washington Wisconsin Wyoming   State #2 Number Expiration Date ** Please Select ** Alabama Arizona California Colorado District of Columbia Florida Georgia Idaho Illinois Indiana Louisiana Maryland Massachusetts Michigan Minnesota Mississippi New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania South Carolina South Dakota Tennessee Texas Utah Virginia Washington West Virginia Wisconsin   State #3 Number Expiration Date ** Please Select ** Arizona Arkansas Colorado Florida Georgia Louisiana Maryland Michigan Mississippi New Jersey North Carolina Ohio Pennsylvania South Carolina Tennessee Texas Vermont Virginia Washington West Virginia Wisconsin   NURSE EXPERIENCE Must have one year of registered nurse experience, and at least one year of that RN experience caring for the elderly and/or chronically ill of any age, and have a current RN license in good standing. List experience in nursing facilities, geriatric departments, chronic care facilities, hospitals, or other long-term care settings. Include brief description of responsibilities. If required include relevant experience in freeform area below. Employer Name* Address* City* State* ZipCode*       ** Please Select ** Alabama Alaska Arizona Arkansas California Colorado Delaware District of Columbia Florida Georgia Illinois Louisiana Maine Maryland Massachusetts Michigan Mississippi Missouri Montana Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Pennsylvania South Carolina South Dakota Tennessee Texas Vermont Virginia Washington Wisconsin Wyoming   Telephone No* Type of Facility* Type of Clients*       Beginning Date* Ending Date* Supervisor's Name & Title*   Summary of duties*:   Reason for leaving*:   Employer Name Address City State ZipCode       ** Please Select ** Alabama Arizona Arkansas California Colorado District of Columbia Florida Georgia Idaho Illinois Indiana Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Pennsylvania South Carolina Tennessee Texas Vermont Virginia Washington Wisconsin Wyoming   Telephone No. Type of Facility Type of Clients       Beginning Date Ending Date Supervisor's Name & Title   Summary of Duties:   Reason for Leaving:   Employer Name Address City State ZipCode       ** Please Select ** Alabama Alaska Arizona Arkansas California Colorado District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania South Carolina Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Telephone No Type of Facility Type of Clients       Beginning Date Ending Date Supervisor's Name & Title   Summary of duties:   Reason for leaving:   If the history does not meet the requirements stated above please include the details to meet requirements. Obra Comments   AVAILABILITY PREFERENCES 1) Available to travel up to   * miles from home address 2) Available for testing administration on the following days (7AM-5PM)? Sun Mon Tue Wed Thu Fri Sat 3) Available for testing administration?   * days per month * True and Complete Information. I certify that all the information provided by me in this document, is true and complete, and I understand that any misstatement, falsification, or omission of information may be grounds for refusal to contract by Credentia Services, LLC, or, if contracted, termination of contract. * OBRA Compliance. I acknowledge that the above information requested in this document is for compliance with the Omnibus Budget Act of 1987, as enacted and amended by the U.S. Congress (“OBRA”), which establishes a requirement for state-approved nurse aide training and competency evaluation testing for long term care facilities. *Licensing. I certify that I am a registered nurse and that I am qualified with the requisite licensing for same. *Certifications. I certify that I have completed and/or as applicable will complete all certification and recertification programs required to meet OBRA and applicable state standards, including but not limited to, certification for test administration, test security, and conflicts of interest. *Independent Business. I certify that I represent to the public that I have an independent business (whether as a sole proprietorship or otherwise) to provide state-approved nurse aide-training and competency evaluation for long-term care facilities.

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