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 2State Requested 3
 
GENERAL INFORMATION
Username*Password*
   
Last Name*First Name*MISocial Security Number*
       
Street Address*City*State*Zip*
     
Home PhoneWork PhoneMobile Phone*Availability Date
     
 
Email Address*
 
 
REGISTERED NURSE LICENSES
Primary State*Number*Expiration Date*
 
 
State #2NumberExpiration Date
 
 
State #3NumberExpiration Date
 
 
 
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*
       
Telephone No*Type of Facility*Type of Clients*
     
Beginning Date*Ending Date*Supervisor's Name & Title*
 
 
 
Summary of duties*:
 
Reason for leaving*:
 
Employer NameAddressCityStateZipCode
       
Telephone No.Type of FacilityType of Clients
     
Beginning DateEnding DateSupervisor's Name & Title
 
 
 
Summary of Duties:
 
Reason for Leaving:
 
Employer NameAddressCityStateZipCode
       
Telephone NoType of FacilityType of Clients
     
Beginning DateEnding DateSupervisor'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)?SunMonTueWedThuFriSat
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.
 
 
 
 
 
 
 
Submit Application