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| | | | | |  | Nurse Aide Evaluator | | | | OBRA COMPLIANCE INFORMATION SHEET | | | | *Denotes required information | | | | | |
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| 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. | |
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| | *Denotes required information |
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| | | | | | 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 | | | | | | | | |
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| 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. | |
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| | 1) Available to travel up to | | miles from home address |
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| 3) Available for testing administration? | | days per month |
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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. |
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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 with no suspensions or felony convictions. | *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. | *Employee Status. I certify that I able to work in my state. | *References. I allow Credentia to contact my references.
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