Form 5509-NAR

Facility Nurse Aide Employment Verification


Field Description/Instructions

Page 1

Facility/Employer Name —  Enter name of entity licensed by the Texas Department of Aging and Disability Services (DADS). List name as it appears on current licensure application.

Annual or Partial List —  If you are submitting your annual Form 5509-NAR listing of all nurse aides who have worked within the past year, check Annual List. If you are submitting a partial list to update nurse aide(s) who will expire before your next annual list is due, check Partial List. If you do not make a selection, the form will be processed as an Annual List.

Address —  Enter mailing address as it appears on current DADS licensure application.

NAR Unique ID —  Enter the identifier assigned by the Texas Nurse Aide Registry (begins with the letters FP or FN).

Facility Representative Name and Title —  Type or print. This individual may be the facility administrator, director of nurses or human resources (HR) authority.

Signatures —  By signing this document, you are verifying that the individuals listed were employed in paid positions and provided nursing or nursing-related services and meets recertification requirements.

Date Form Completed —  This date will be used to establish last known date of employment for individuals listed as employed to " present." Forms will be processed based on the date actually received in the Nurse Aide Registry.

Page 2

Status —  Leave blank (Texas Nurse Aide Registry use only).

Nurse Aide Name —  Enter employee's last name, first name and middle initial.

Nurse Aide Certificate Number —  If applicable, enter the nurse aide's Texas certificate number.

Social Security Number —  Enter the nurse aide's nine-digit Social Security number.

Period of Employment — 

From —  Enter the first date the nurse aide actually worked for facility/employer.

To —  Enter the last date the nurse aide actually worked for facility/employer. If the nurse aide is currently employed, you may enter "present." (Texas Nurse Aide Registry will enter the date the form is completed as the latest date worked.) If the individual has had more than one employment period with your facility during the year, please indicate each period of employment on a separate line.