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5506 Nar

Form 5506-NAR is an Employment Verification form for Texas Nurse Aides that requires completion by both the nurse aide and their employer, including notarization. The form must be submitted through the TULIP account for Certified Nurse Aide Renewal and includes verification of specific requirements for recertification. Incomplete requests or those lacking required documents will not be processed by the Texas Nurse Aide Registry.

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Adilene Loera
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79 views2 pages

5506 Nar

Form 5506-NAR is an Employment Verification form for Texas Nurse Aides that requires completion by both the nurse aide and their employer, including notarization. The form must be submitted through the TULIP account for Certified Nurse Aide Renewal and includes verification of specific requirements for recertification. Incomplete requests or those lacking required documents will not be processed by the Texas Nurse Aide Registry.

Uploaded by

Adilene Loera
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Form 5506-NAR

December 2024
Texas Nurse Aide Registry
Employment Verification

The nurse aide completes this form. Read the following instructions before completing.

• Complete all information in Section 1 and sign to verify the information provided is correct.
• Get employer verification in Section 2. Employer must sign and date in front of a notary.
• Form must be submitted to your TULIP account by creating the Certified Nurse Aide Renewal application at txhhs.my.site.com/TULIP/s/login/.
• To verify your Certified Nurse Aide (CNA) certification, use emr.dads.state.tx.us/DadsEMRWeb/.
• Note: Find a list of approved in-service education programs at hhs.texas.gov/nar-cbts or Approved In-Service Education Program (Excel) on
hhs.texas.gov/business/licensing-credentialing-regulation/long-term-care-credentialing/nurse-aide-registry
The Texas Nurse Aide Registry will return without action incomplete requests and requests without the required documents.

Section 1 – Applicant's Information


Applicant’s Last, First, Middle Name Maiden Name if applicable

Date of Birth Social Security No. CNA Certificate No.

Email Address

Verification of requirements for Nurse Aide Recertification

1. Are you listed on the Employee Misconduct Registry (EMR) as unemployable? .................................................................... Yes No

Do you have a conviction of a criminal offense listed in Texas Health and Safety Code, Section 250.006? Yes No

3. Have you completed 24 hours of in-service education in the past two years? ......................................................................... Yes No

4. Have you completed an HHSC course in infection control and proper use of personal protective equipment (PPE) once
each year in the past 24 months? ............................................................................................................................................ Yes No

Nurse Aide Signature Date

Proceed to page 2 to complete this form.


Form 5506-NAR
Page / 12-2024

Section 2 – Employer's and Company Information


The actual employer must complete this section. Employer must sign and date in front of a notary and return to nurse aide.
Employer Name or Company Name Daytime Area Code and Phone No.

Mailing Street or P.O. Box Address City State ZIP Code

I certify that the person named above is or was employed by me as a nurse aide and performed nursing or nursing-related services from
(mm/dd/yyyy) to (mm/dd/yyyy) and that I am not aware of any disqualifying misconduct.

Comments

Signature – Employer Date

Sworn and subscribed to me on this day of , 20 , in


County, in the state of .

Signature – Notary Public Date Commission Expires

Place Notary Seal


or Stamp Here

Tampering with, or attempting to falsify, a government record such as a nurse aide certificate is a third-degree felony punishable by
up to 10 years in prison and a $10,000 fine.

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