Application For Registered Long-Term Care Nurse Aide (Rltcna) By Reciprocity
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1
2STATE OF WEST VIRGINIA
DEPARTMENT OF HEALTH AND HUMAN RESOURCES
OFFICE OF INSPECTOR GENERAL
Earl Ray Tomblin
Karen L. Bowling
OFFICE OF HEALTH FACILITY LICENSURE
Governor
Cabinet Secretary
AND CERTIFICATION
LONG-TERM CARE NURSE AIDE PROGRAM
APPLICATION FOR REGISTERED LONG-TERM CARE NURSE AIDE
(RLTCNA) BY RECIPROCITY
Independent private duty services are no longer considered acceptable employment for reciprocity or re-registration,
effective July 1, 2006. Print clearly or type the information requested and return to the address listed on page 2.
This office is allotted a two (2) week time frame to conduct a review of all reciprocity applications from the date they are
received. You will want to submit your completed application in a timely manner in order to prevent delay in processing.
Applicant’s Full Name:
Last
First
Middle
Maiden
-
-
(
)
Social Security Number
Area Code
Telephone number
Mailing Address (PO Box #, or House # and Street Name)
City
State
Zip
County
/
/
Sex:
(Optional)
(Required to grant Reciprocity)
Date of Birth
Name and Address of Training Program:
(Required to grant Reciprocity)
Phone#:
Date Completed Training Program:
Date Placed on Registry:
Month/Day/Year
Registration Number:
Expiration Date:
Provide copies of the training completion certificate or registration notice letter or card.
NA Employment Section:
List all Nurse Aide related employment for the past three (3) years.
Employer #1:
Name:
Phone Number:
Address:
City, State, Zip:
Duties:
Feeding
Vital Signs
ADL’s
Bed making
Catheter care
Activities
Height/Weight
Laundry
Transfer/lifting
Transporting
DATE HIRED:
DATE LEFT:
(Month/Day/Year)
(Month/Day/Year)
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