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area CODe area CODe. 5. e-mAil AddRess. 6. RegisTRATiON fOR eXAm ...
Mississippi Nurse Aide Program APPLICATION for the NNAAP® examination Please Print LEGIBLY — use ink only Reciprocity candidates should NOT use this application; they should use “Reciprocity Application” at http://www.asisvcs.com/publications/pdf/072503.pdf
1. Social Security Number:
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Date of Birth:
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D D
Y
Y
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Y
2. print full name
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middle initial
first maiden name (If Applicable)
3. mailing address
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PO Box
City State ZIP Code
4. phone number Daytime Phone Number:
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Alternate Phone Number:
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Area Code Area Code
5. e-mail address 6. REGISTRATION FOR EXAM & FEES (All candidates MUST CHECK one of the following exam types.) If you are currently employed by or have a written offer or signed acceptance of employment as a nurse aide in a long-term care facility that participates in Medicaid/Medicare programs, your employer must pay the examination fee and any retest fee. 1. ■ Written Exam and Skills Evaluation (both). . . . . . . . . . $101 2. 3.
4. ■ Skills Evaluation Exam ONLY (retest) . . . $69
■ Oral Exam and Skills Evaluation (both) . . . . . . . . . . . . 101 5. ■ English Oral Exam ONLY (retest). . . . . . . $32 ■ Written Exam ONLY (retest). . . . . . . . . . . . . . . . . . . . . . . $32 Fees MUST accompany ALL applications and are NON-REFUNDABLE. $
Fees may be paid by certified check, company check, or money order only. Checks are to be made payable to “NACES Plus Foundation.” Personal checks or cash will not be accepted. 7. I WANT TO TEST: (You MUST check one option below.)
n At a Regional Test Site Provide the test site code and the location of the test site in which you prefer to test. The Regional Test Sites and the RTS Codes may be found as a link labeled Regional Test Sites on the Mississippi Nurse Aides page of the Pearson VUE web site (www.pearsonvue.com).
Site Test Site rts Code: City/Town:
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If your choice of test site is not available, would you be willing to travel for a sooner test date? If YES, would you be willing to travel up to
■ Yes ■ No
■ 30 miles ■ 45 miles ■ 60+ miles for the first available test?
n At a State-Approved In-Facility Test Site (Complete the information below and submit your completed application to your training program instructor.): Training Training Program Name:______________________________________________Test Date:_________________________ Program Code:
Copyright © 2014 Pearson Education, Inc. or its affiliate(s). All Rights Reserved.
[email protected]
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Stock# 0725-01
11/14
8. ELIGIBILITY ROUTES (You MUST SELECT ONE of the following Eligibility Routes.) All applicants must pass both portions
of the exam within two (2) years from the training program completion date (unless you trained at a Facility-based program) or within three (3) attempts, whichever comes first, in order to be placed on the Mississippi Nurse Aide Registry. If you trained at a Facility-based program you must pass both portions of your exam within 120 days of your hire date or within three (3) attempts, whichever comes first. Failure to do so will require completion of a Mississippi State Approved Nurse Training Program and retesting both portions of the examination. n Nurse Aide Candidate trained in MS — NON-Facility-based and proprietary schools and colleges (Your training program must complete Section 9 below.) Must have successfully completed a MS state-approved nurse aide training program within the last 24 months. n Nurse Aide Candidate trained and employed in MS – Facility-based (Nursing Home) (Your training program must complete this information and Section 9 below.) Must have successfully completed a MS state-approved facility-based nurse aide training program. Candidate MUST be certified within 120 days of his or her hire date. You MUST Enter your HIRE DATE BELOW. For Facility-based Programs — Enter your HIRE DATE HERE:
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n Student Nurse — Candidate must have successfully completed the fundamentals/basic nursing skills section of a state approved LPN or RN program within the past twenty-four months. Please contact MS State Department of Health to determine if the program is approved. Note: If approved and the student is eligible to test, the application must be signed by the instructor and submitted with a training completion certificate. n Graduate Nurse — An individual who has completed a Mississippi approved RN or LPN program within the past twenty-four months. Graduate must submit examination application, fees, and a copy of an LPN or RN training completion certificate diploma or certificate to be eligible to take the NNAAP Examination. n Out of State or Foreign LPN or RN — Must have completed an LPN or RN program outside of the state of Mississippi. Section 9 of this application must be completed by the Mississippi State Department of Health. You must submit this application to the Mississippi State Department of Health at P.O. Box 1700, Jackson, MS 39215 to determine your eligibility before submitting to NACES. n Lapsed Nurse Aide — Candidate is lapsed on the Mississippi Nurse Aide Registry and must retest in order to become “Active” on the registry. If you fail either the written exam or the skills evaluation on the first attempt you will be required to complete a Mississippi state-approved nurse aide training program before retesting and submit a new application as a New Nurse Aide. You must supply your Mississippi nurse aide certificate number and lapsed date or your application will not be processed. certificate number:___________________________________________________ lapsed date:__________________________________________
n Petition for Removal of Finding of Neglect — An individual whose nurse aide certification has been revoked due to one
finding of Neglect and whose certification has been revoked for a minimum of one year (12 months). Individual must have no additional findings of neglect during that time, and must re-test in order to become “Active” on the MS Nurse Aide Registry. If you fail either part of the NNAAP Examination the Petition for Removal of a Finding of Neglect will not be reviewed and consideration for removal of the finding of neglect from the MS Nurse Aide Registry will be denied. You must supply your Mississippi nurse aide certificate number and the date your certification was revoked or your application will not be processed. Note: If you selected this Eligibility Route your application information will be forwarded to the Mississippi State Department of Health for review before you can be scheduled to test. You may be asked to provide additional information for review, which may cause a delay in your testing.
certificate number:________________________________________________ Date certification was Revoked:______________________
9. PROVIDE TRAINING PROGRAM INFORMATION AND A COPY OF YOUR CERTIFICATE OF COMPLETION
• I f you checked Nurse Aide Candidate trained in MS – Facility Based or NON-Facility Based, this section must be completed and signed by the training program. If your training program is no longer in business, please contact the Mississippi State Department of Health at (601) 364-1100. • If you checked Graduate Nurse, you must provide a copy of your LPN or RN certificate and indicate 9999 for the training program code number. Training Program Name:___________________________________________________________________________________________________________ Training Program Code:
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Training Program Completion Date:*
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*Training program completion date must match the completion date on your certificate of completion. SIGNATURE OF TRAINING PROGRAM INSTRUCTOR/COORDINATOR: _____________________________________________________________________________ DATE:
____________________________
10. CANDIDATE STATEMENT AND SIGNATURE (All candidates MUST sign.) I understand that I am responsible for making
sure that all of the information provided in this application is completely true and correct. I understand that any information I give that is not true may jeopardize my certification status and listing as a nurse aide, and may result in prosecution by the state of Mississippi. I confirm that I am not deemed unemployable or have had a conviction of any criminal offense. SIGNATURE OF APPLICANT: ______________________________________________________________________________ DATE: _____________________________
MAILING INFORMATION MAIL TO: NACES Plus Foundation, Inc • 8501 North Mopac Expressway, Suite 400 • Austin, Texas 78759
YOU MUST MAIL TOGETHER IN ONE ENVELOPE: n 1. Your completed application, copy of your Training Program Certificate or diploma (if applicable), and fees. n 2. Correct exam fees (which are non-refundable) n 3. If you are requesting an ADA Accommodation you must include all supporting documentation with this application. (See Mississippi Candidate Handbook under Special Exam Requests and Services.) If you do not receive an Authorization to Test Notice (yellow confirmation card) within ten (10) business days of mailing your application, call NACES at (800) 579-3321. NACES is not responsible for lost, misdirected, or delayed mail delivery. If you cannot attend your scheduled exam date, you MUST call NACES by noon at least five (5) business days before the test date to reschedule or you will forfeit your exam fees.
