Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62696 (11/08)

STATE OF WISCONSIN
Chapter 146.40, Wis. Stats.

STUDENT NURSE / GRADUATE NURSE TRAINING VERIFICATION
· Prior to issuing approval to take the State of Wisconsin nurse aide competency examination, the Department of Health Services reviews the training of all student nurses and graduate nurses who have not yet taken the NCLEX examination. Completion of this form is mandatory, as the information collected on this form is used to determine if federal and state nurse aide training program requirements have been met by the nurse candidate. Providing the candidate's social security number is voluntary; however, social security numbers are one of the unique identifiers used to prevent incorrect identity mismatches; e.g., the Department of Justice uses social security numbers, names, sex, race, and date of birth to prevent incorrect matches of persons with criminal convictions. You will not be approved to schedule for a nurse aide examination date without the completion of this form and a copy of your OFFICIAL TRANSCRIPTS. Mail this completed form to: Nurse Aide Training Consultant P.O. Box 2969 Madison, WI 53701-2969 Print neatly in BLACK INK or TYPE.

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I. PERSONAL INFORMATION
Name Social Security Number Telephone Number

Address

City

State

Zip Code

II. EDUCATION
Your nursing instructor must indicate the specific, completed course number for the courses in which the following criteria was taught and in which the minimum of 32 hours of "hands on" clinical experience was obtained. Aging Process: Basic Nursing Skills: Basic Restorative Skills: Death/Dying: Care of Cognitively Impaired: Communication Skills: Infection Control: Personal Care Skills: Safety/Emergency Procedures: Residents' Rights:

Clinical Course: Name ­ Facility Type of Facility

SIGNATURE ­ Instructor

Name ­ Instructor (Print or type.)

Date Signed

DHS USE ONLY Approved Approval Pending, Information Needed Denied Reason for Denial

Name - Reviewer

Title

Date