How to Submit Forms and Applications
Fax the following forms and applications to the Division of Health Service Regulation at 919-733-9764. You must use the most current version of each form and application.
- Name and Address Change Form
- Reciprocity Application
- RN and LPN Form
Complete the following application using Credentia’s CNA365 system. Click here to go to Credentia’s website.
- Training Waiver Application
Complete the following forms online at the Division of Health Service Regulation website:
- Nurse Aide Online Renewal Form
- Nurse Aide Online Employment Verification Form
- Medication Aide Online Renewal Form
- Medication Aide Online Employment Verification Form
Guidelines for the Online Renewal Forms – Nurse Aide:
- The Nurse Aide should submit separate Online Renewal Forms for listings in the North Carolina Nurse Aide I Registry and the North Carolina Medication Aide Registry for Nursing Homes.
- The Nurse Aide can submit the Online Renewal Form within 90 days prior to the listing expiration date and up to 24 months past the listing expiration date. Please be advised that the last date worked as a Nurse Aide must be within the registration/listing period identified in the form.
- The online renewal forms do not renew a Nurse Aide II listing with the North Carolina Board of Nursing.
Guidelines for the Online Renewal Forms – Technology:
- Do not use the Internet Explorer web browser when completing the forms.
- Do not use a smart phone when completing the forms.
- Do not enter commas (,) in the text fields to separate information in the Online Renewal Form or the Online Employment Verification Form.
- Contact your Information Technology department within your organization to ensure firewalls will allow the online renewal forms to be submitted to DHSR.
Guidelines for the Online Renewal Forms – First Name and Last Name Requirements:
- The First Name and Last Name entered in the online renewal forms must match the First Name and Last Name listed in the North Carolina Nurse Aide I Registry – including hyphens and suffixes.
- The Nurse Aide should complete the Name and Address Change Form If their legal name is not reflected in the Nurse Aide I Registry. Click here to obtain the Name and Address Change Form.
- Do not include apostrophe’s when entering the First Name or Last Name. If the First Name or Last Name includes an apostrophe in the registry, and that is the correct spelling of the name, then there is no need to complete the Name and Address Change Form.
Guidelines for the Online Renewal Forms – Registered Nurse:
- The Registered Nurse must have an active and unencumbered license to practice in North Carolina.
- The Registered Nurse must be the direct supervisor of the Nurse Aide or has direct access to employer files. Employment that the Registered Nurse cannot support within the employer files or by personal supervision (and thereby knowledge of the employment date) does not meet the requirements for renewal.
- The Registered Nurse is not attesting to the competency of the Nurse Aide.
- The Registered Nurse should submit separate Online Employment Verification Forms for listings in the North Carolina Nurse Aide I Registry and the North Carolina Medication Aide Registry for Nursing Homes.
- The Registered Nurse must submit the Online Employment Verification Form within 7 calendar days after the Nurse Aide submits the Online Renewal Form. After 7 days, both online renewal forms must be submitted again to DHSR.
- The Registered Nurse is not required to enter dashes (-) when entering their license number.
- The Registered Nurse can find the facility license number by completing one of the following activities below:
- Review the DHSR licensure certificate posted within the healthcare facility.
- Click here to review DHSR facility information for your provider type (e.g., nursing home, hospital, etc.).
- Click here to find the contact information for the DHSR Licensure Section for your provider type (e.g., nursing home, hospital, etc.).
Denotes link to site outside of N.C. DHHS
