Fillable *APPCNAFL* Florida Certified Nursing Assistant Examination Application

Fill Online, Printable, Fillable, Blank *APPCNAFL* Florida Certified Nursing Assistant Examination Application Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

*APPCNAFL* Florida Certified Nursing Assistant Examination Application

On average this form takes 58 minutes to complete

The *APPCNAFL* Florida Certified Nursing Assistant Examination Application form is 7 pages long and contains:

  • 0 signatures
  • 16 check-boxes
  • 226 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
*APPCNAFL*
APPCNAFL 1 Rev. 20190806
Florida Certified Nursing Assistant
Examination Application
Instructions:
Please go to www.prometric.com/NurseAide/FL to print the current version of this application and all
other forms. DO NOT submit photocopies as this may impact the ability to process the application.
Incomplete, blurred or illegible forms will not be processed.
To apply online please go to: www.prometric.com/NurseAide/FL.
All submitted applications must include the Payment Form at the end of the application.
Please mail completed original forms to Prometric, ATTN: FL Nurse Aide Program, 7941 Corporate Drive,
Nottingham, MD 21236.
If applying for Testing Accommodations under the Americans with Disabilities Act (ADA):
Please go to to www.prometric.com/nurseaide to print the required ADA Accommodations
Request Packet. This packet MUST be completed and submitted with this application.
Fill out the box below.
Note: Candidates applying to take the Oral (audio) Exam do not need to apply for ADA accommodations.
Candidate Information
All fields marked with * are required. Print one number/letter in each box where required.
*Have you taken the CNA Written or Clinical Skills test before, in Florida, since 2002?
No Yes If yes, when was the last time you took the test: __________________
*First Name

Middle Initial
*Last Name


I am applying for Americans with Disabilities Act (ADA) accommodations. I am requesting
testing accommodations and have included the required ADA Accommodations Request
Packet along with this application. I understand I must request accommodations 30 days in
advance of the test date and not all accommodations can be approved.
Yes No
The name you provide on this application must match EXACTLY the name on your government-
issued identification you will provide on the day of testing. If the name does not match EXACTLY,
you will not be permitted to take your exam and will forfeit any test fees.
If you have previously taken a nurse aide exam with Prometric and your legal name has changed
since then, you must provide a copy of acceptable legal documentation along with this
application. Acceptable documents include marriage certificate; divorce decree; birth certificate;
and legal name change court documents. Prometric will be unable to process your application until
the legal acceptable documents are received.
2 Rev. 20190806
*Date of Birth (Month/Day/Year)
//
Previous name (if applicable):
*Street Address (including Apt. number or P.O. Box, if applicable)
*City *State *ZIP Code
 
* Phone Number (including area code)
--
*Email Address (application will not be processed without an email address)
Race (optional)
White Black Native American
Hispanic Asian/Pacific Islander Other
Gender (check one) Female Male
Do you have a High School Diploma or equivalent? YES NO
*Criminal and Medicaid/Medicare Fraud Questions (Mandatory)
IMPORTANT NOTICE: Applicants for licensure, certification or registration and candidates for examination may
be excluded from licensure, certification or registration if their felony conviction falls into certain timeframes as
established in Section 456.0635(2), Florida Statutes. If you answer YES to any of the following questions, please
provide a written explanation for each question including the county and state of each termination or conviction,
date of each termination or conviction, and copies of supporting documentation. All supporting documentation
should be sent to the Florida Department of Health. Supporting documentation includes court dispositions or
agency orders where applicable. NOTE: This notice only applies
to questions 1-5 below.
*1.
Yes No
Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of
adjudication, a felony under Chapter 409, F.S. (relating to social and economic assistance),
Chapter 817, F.S. (relating to fraudulent practices), Chapter 893, F.S. (relating to drug
abuse prevention and control) or a similar felony offense(s) in another state or jurisdiction?
(If you responded "No" to question 1, skip to question 2.)
a. Yes No
If "Yes" to 1, for the felonies of the first or second degree, has it been more than 15 years
before the date of this application?
b. Yes No
If "Yes" to 1, for the felonies of the third degree, has it been more than 10 years before the
date of this application, except for felonies of the third degree under Section 893.13(6)(a),
Florida Statutes?
c. Yes No
If “Yes” to 1, for felonies of the third degree under Section 893.13(6)(a), Florida Statutes,
has it been more than 5 years before the date of this application?
d. Yes No
If "Yes" to 1, have you successfully completed a pretrial diversion or drug court program for
a felony offense that resulted in the plea being withdrawn or charges dismissed?
e. Yes No
If “Yes” to 1, were you arrested or charged for the felony before July 1, 2009?
*2.
Yes No
Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of
adjudication, a felony under 21 U.S.C. ss. 801-970 (relating to controlled substances) or 42
U.S.C. ss.1395-1396 (relating to public health, welfare, Medicare and Medicaid issues)?
(If you responded “No” to question 2, skip to question 3.)
3 Rev. 20190806
a. Yes No
If "Yes" to 2, has it been more than 15 years before the date of application since the
sentence and any subsequent period of probation ended for the conviction or plea?
b. Yes No
If "Yes" to 2, were you arrested or charged for the felony before July 1, 2009?
*3.
Yes No
Have you ever been terminated for cause from the Florida Medicaid Program under Section
409.913, Florida Statutes?
(If you responded "No" to question 3, skip to question 4.)
a. Yes No
If you have been terminated but reinstated, have you been in good standing with the Florida
Medicaid Program for the past 5 years?
*4.
Yes No
Have you ever been terminated for cause, pursuant to the appeals procedures established by
the state, from any other state Medicaid program?
(If you responded "No" to question 4, skip to question 5.)
a. Yes No
Have you been in good standing with a state Medicaid program for the past 5 years?
b. Yes No
Did the termination occur at least 20 years before the date of this application?
*5.
Yes No
Are you currently listed on the United States Department of Health and Human Services
Office of Inspector General's List of Excluded Individuals and Entities?
*Disciplinary History (Mandatory)
Yes No
Have you ever been denied or is there now any proceeding to deny your application for any
healthcare certification to practice in Florida or any other state, jurisdiction or country?
Yes No
Have you ever had disciplinary action taken against your certification to practice any
healthcare-related profession by the licensing authority in Florida or in any other state,
jurisdiction or country?
Yes No
Have you ever surrendered a certification to practice any healthcare-related profession in
Florida or in any other state, jurisdiction or country while any such disciplinary charges were
pending against you?
Yes No
Do you have any disciplinary actions pending against your certification?
*Criminal History (Mandatory)
Yes
Have you EVER been convicted of, or entered a plea of guilty, nolo contendere, or no
contest to, a crime in any jurisdiction other than a minor traffic offense? You must include all
misdemeanors and felonies, even if adjudication was withheld.
Reckless driving, driving while license suspended or revoked (DWLSR), driving
under the influence (DUI) or driving while impaired (DWI) are not minor traffic
offenses for the purposes of this question.
If you answered YES, please be prepared to create a typed or printed letter with arrest
dates, city, state, charges and final dispositions and be prepared to send it to the Board
Office upon request. (Do not send this information with your application for examination.)
Have you EVER had any records sealed pursuant to section 943.059, F.S., or any other
states applicable statute
Have you EVER been adjudicated delinquent or have had adjudication of delinquency
withheld?
4 Rev. 20190806
*Health History (Mandatory)
If you answer “Yes” to any of the questions in this section, all supporting documentation should be sent to the
Florida Department of Health.
1. Yes No
Do you have any condition that currently impairs your ability to practice your
profession with reasonable skill and safety?
2. Yes No
Are you using medications, other drugs, narcotics, or intoxicating chemicals that
impair your ability to practice your profession with reasonable skill and safety?
*Social Security Number
--
Pursuant to 466(a)(13), 42 U.S.C. §666(a)(13), the department is required and authorized to collect Social
Security Numbers relating to applications for professional licensure. Additionally, section 456.013(1)(a), Florida
Statutes, authorizes the collection of Social Security Numbers as part of the general licensing provisions. This
information is exempt from public records disclosure.
Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by
federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code,
Sections 653 and 654; and Section 456.013(1), 409.2577 and 409.2598, Florida Statutes. Social Security numbers
are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to ensure
compliance with child support obligations. Social Security numbers must also be recorded on all professional and
occupational license applications and will be used for license identification pursuant to the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act. 104 Pub.L.Section 317). Clarification of the
SSA process may be reviewed at www.ssa.gov or by calling 1-800-772-1213.
If you answered “Yes” to any of the questions in this section, you are required to send the
following items:
• Please provide a letter from a licensed health practitioner, who is qualified by skill and training to
address your condition, which explains the impact your condition may have on your ability to
practice your profession with reasonable skill and safety, and stating either that you are safe to
practice your profession without restriction or indicating what restrictions are necessary. If
necessary, you may attach additional sheets. Documentation must be current within the last year.
If you fail to disclose the information requested in this section, your application may be denied.
• Self Explanation, explaining the medical condition(s) or occurrence(s) and current status.
5 Rev. 20190806
*Certification Option/Eligibility
Please check a certification route.
Certification Training Route
E1 - Completed a State-approved Nursing Assistant Training Program. (Complete Training Info section
below).
E2 - Enrolled in a State-approved Nursing Assistant Training Program. (Complete Training Info section
below).
E3 - Challenger. You have never trained as a nursing assistant and have no nursing assistant experience.
E4 - Other Nursing Training.
E5 - Lapsed Nursing Assistant.
Training Information
This section must be completed if the applicant has selected Training Route E1 or E2.
*Training Completion Date:
//
*Training Program Code (if available – see completion
certificate)
*Name of School or Facility
*Address of School or Facility (Street Address or P.O. Box)
City State  ZIP Code 
*Test Site Information
Please check one of the following options.
Test Site
Testing at your Facility: My training program or employer is scheduling my exam and I will take the
exam at their facility. I will give this application form to the facility coordinator. Do not send to
Prometric.
Regional Test Site: I am applying to test at a Regional Test Site. My preferred
test site code is listed.
A current list of Test Sites with codes can be found online at www.prometric.com/NurseAide/FL.
*Test Site Code:
Exam Selection and Processing/Exam Fees
Acceptable Forms of Fee(s) Payment: certified check, money order, MasterCard, Visa or American
Express. Make certified checks payable to Prometric. Personal checks and cash are not accepted. Fees
are non-refundable and non-transferrable.
The Payment Form (last page) must be submitted with this application regardless of payment type.
Exam (Check all that apply)
Fee
Total
Clinical Skills and Written (both in English)
$155
$
Clinical Skills and Written Oral(both in English)
$155
$
Written (English)
$35
$
Written Oral (English)
$35
$
Clinical Skills (English)
$120
$
Clinical Skills (English) and Written (Spanish)
$155
$
Clinical Skills (English) and Written Oral (Spanish)
$155
$
Written (Spanish)
$35
$
Written Oral(Spanish)
$35
$
Total Fee
$
An additional rescheduling/no show fee of $25 is required to reschedule an exam appointment with less than five business days notice, no-
shows, late arrivals, or not allowed to test. Reschedule fees may apply to roster changes made by IFT testing locations.
6 Rev. 20190806
*Applicant’s Affidavit and Candidate Release Statement
*Electronic Fingerprints
Please review the Florida Department of Law Enforcement statement and the Federal Bureau of
Investigation document located in the ‘Forms’ section of the Candidate Bulletin.
I have been provided and read the statement from the Florida Department of Law Enforcement
regarding the sharing, retention, privacy and right to challenge incorrect criminal history records
and the “Privacy Statement” document from the Federal Bureau of Investigation. (Located in the
Candidate Bulletin available online).
Yes No
*Candidate Attestation
• I understand I am responsible for making sure all information provided in this application is
completely true and correct.
• I understand if information given is not true, my registration status as a nursing assistant may be at
risk.
• I understand if I pass both parts of the Nursing Assistant Competency Exam, I will be placed on the
Registry.
• I understand I may be asked to play the part of the resident for another candidate on exam day. I
do not have any physical, medical or other condition that would be affected in any way by my
participation in the exam. I agree I am responsible for my own personal safety both while taking the
exam and acting as a resident. I hereby release Prometric, the FLDOH, and their agents and assigns
from any responsibility or liability for any claim or damage that may result from my participation in
the examination.
• I understand all information required on the registration application may be made available for
public disclosure (except for the Social Security Number).
*Candidate Signature (in box below)
Date: _______________________
If you DO NOT receive your emailed ATT letter from Prometric within 10-14 business days of receipt at
Prometric, please contact Prometric.
Questions: For additional information, please visit our website at www.prometric.com/nurseaide.
Please make a copy of all completed forms for your personal records.
*PAYCNAFL*
PAYCNAFL 7 Rev. 20190806
Payment Form
*Candidate Name: _____________________________________
*Date of Birth: ______________________
Note: You have the option of submitting your application and payment online using your credit card at
www.prometric.com/en-us/clients/nurseaide.
Credit Card Type (Check One)
MasterCard Visa American Express
Card Number
Expiration Date
/
Amount
$ __ __ __ . __ __
C/C Security Code

Name of Cardholder (Print)
Signature of Cardholder
Certified Check or Money Order Payments
Certified Check 3
rd
Party/Facility Check Money Order
Certified Check/Money Order/3
rd
Party/Facility Check Number (one number or letter in each box):

Please mail completed forms to:
Prometric
ATTN: FL Nurse Aide Program
7941 Corporate Drive
Nottingham, MD 21236.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

*APPCNAFL* Florida Certified Nursing Assistant Examination Application

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 4 May 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document