State of Illinois
Illinois Department of Public Health
Manual Skills Evaluation Form
either by evaluation (grandfathered in - military trained - nursing student - foreign LPN/RN –
inactive out of state CNA) or by completing an Illinois Approved Nurse Aide Training Program. This
individual has not worked for pay for 24 consecutive months or longer since his or her last
Competency Exam. This individual is now taking steps to regain his or her approved certification.
successfully passed all 21 Manual Skills.
Social Security Number
Street Address
, ,
City, State, Zip Code
Telephone
Skills Evaluation Site
Evaluator’s Code
Evaluator’s Name (Print or Type)
Evaluator’s Signature
Use your Approved Evaluator (AE) credentials to
submit applicant information through the INACE
online registration system.
Date Completed
Distribution: Give one copy to nurse aide. Keep a copy for your records.
CNA’s Name
(Print or Type)
The nursing assistant listed below was previously deemed competent as a certified nurse aide The nursing assistant listed below was previously deemed competent as a certified nurse aide
I have administered the Manual Skills Competency Test to this individual and he or she has
CNA's Email
Evaluator’s Email
Southern Illinois University Nurse Aide Testing
1840 Innovation Drive, Suite 103, Carbondale, IL 62903
Phone: 877-262-9259 Fax: 618-453-4300 Email: wednat@siu.edu
Date of B
irth
* All form fields are required.
