APPLICATION FOR NEBRASKA NURSE AIDE REGISTRY BY INTERSTATE ENDORSEMENT
If you are a nurse aide in another state and want to work in Nebraska, you must be active on the Nebraska Nurse Aide Registry before
you are eligible to work in a certified nursing facility. Nebraska requires a minimum 75-hour nurse aide training, passing scores on
written and clinical exams, and nurse aide employment in the last 24 months (if you have not tested in the last 24 months.) All aides
coming into Nebraska from another state must also have Nebraska’s one-hour in-service on reporting abuse and neglect. If your first
Nebraska employer will not give you this in-service, it can be obtained at some of the community colleges or on-line. We process
applications in order received and it can take up to 30 days to process your application after receipt. If your application is not complete,
we will send you a deficiency letter. If your application is complete, we will issue your registration (license) number and place
you on the website where employers can find you. We do not issue licensure cards for Nurse Aides and we do not send you
any notification that we have issued your registration number. You can print your registration information from the website
which is updated every day about 8:00 am. You can pull up your record by entering just your first and last names. The website
address is http://dhhs.ne.gov/publichealth/Pages/crl_nursing_na_na.aspx Click on “Accessing the Nurse Aide Registry.”
Please print clearly. If you are unsure of your answer, please give as much information as you can and put a question mark after your
answer. Please attach a copy of your licensure card if you have one and a copy of your training document if your training cannot be
verified with the Nurse Aide Registry in the state where you had your training.
1. Name:
(Last) (First) (Middle)
2. Maiden Name/Previously Used Names:
3. Mailing Address:
(Street Address, Apt Number, PO Box Number) (City) (State, Zip)
4. E-Mail Address:
5. Telephone Number: 6. Social Security Number (Required):
7. Date of Birth (Required): 8. Place of Birth (City/State):
9. Name of Facility/College Where Nurse Aide Training Course Taken:
10. City/State Where Training Course Taken:
11. Total Number of Course Hours: 12: Course Completion Date:
13. Have you passed the exams? No Yes If yes, in what state? 14. Date Approved:
15. If you are approved or have worked in any other states as a nurse aide besides the one listed above, please list those states:
State
Date Approved or Dates Worked Registration or Certification #
16. Have you tested or been employed as a Nursing Assistant during the past 24 months? Yes No
17. Please list nurse aide employers during the past 24 months. (If you were previously registered in Nebraska, please list all nurse aide
employment since you last worked in Nebraska—you may continue on the back or attach a separate sheet, if needed.)
Facility Name or Name of Employer
City/State Phone # Dates Worked (Month/Day/Year)
From:
To:
From:
To:
I authorize DHHS to request information
regarding my Nurse Aide registry status
from the states and employers identified
above at their discretion.
(Applicant Signature)
(Date Signed)
Return this form to:
Nebraska Nurse Aide Registry
ATTN: Wanda Vodehnal
PO Box 94986
Lincoln NE 68509-4986
Fax: 402-471-1066
E-Mail: wanda.vodehnal@nebraska.gov
PH: 402-471-4971
Revised 02-13-14
