Free 49937.pdf - Indiana

NURSE AIDE REGISTRY CNA RENEWAL
State Form 49937 (R3 / 9-08)

INDIANA STATE DEPARTMENT OF HEALTH-DIVISION OF LONG TERM CARE

INDIANA DEPARTMENT OF HEALTH LONG TERM CARE 2 N Meridian Street RM 4B Indianapolis, IN 46204 Telephone: 317-233-3742 Fax number: 317-233-7750

*Your Social Security number is requested in accordance with the provision of IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

On an annual basis, the employer must inform the Indiana State Department of Health (ISDH) Nurse Aide Registry (NAR) that an individual Certified Nurse Aide (CNA) has performed "nursing or nurse-related services" activities for at least an eight-hour shift during a 24-month consecutive time period. Please complete this form for each CNA who has worked at least 8 hours in a 24-month period. Based upon receipt and completion of this form, each CNA will be renewed for a 2-year period.

I.

AIDE CERTIFICATION

Full Name of CNA CNA Street Address City CNA Telephone Social Security Number* Date of Hire Job Title II. CNA JOB FUNCTION

Zip Code Date Of Birth CNA Registration Number Date of Termination CNA Expiration Date

State

Please identify the number of hours within the last 24 consecutive months that this individual has performed "nursing or nursing-related services."

Number of Hours III. AGENCY IDENTIFICATION

Director's/RN's Name Name of Health Care Facility Facility Street Address City Facility Number

State

Zip Code

I hereby attest that the above information is true and accurate.

______________________________________________ Director's/RN's Signature

______________________ Date

FOR OFFICE USE ONLY Expiration Date Renewal Date

Not on NAR Initials

Date