Forrm Doh 667-005 - Out Of State Credential Verification Form printable pdf download

Nursing Assistant Credentialing

P.O. Box 47877

Olympia, WA 98504-7877

360-236-4700

Out of State Credential Verification Form

Mail this form to the state you are coming from. They will return it to the Washington State Department of Health.

Part I: To Be Completed By Applicant

I am listed on the Nurse Aide Registry in the state of _______________________________ under the name of

__________________________________________ and my registration number is _______________________

Social Security Number ______________________ Telephone Number ________________________________

Mailing Address ___________________________________________________________________________

 I completed a nursing assistant training program at ______________________________ on___________ .

mm/dd/yyyy

Training Site

 I completed a competency examination on ___________________________ .

mm/dd/yyyy

 I became a nursing assistant by waiver or deeming.

 I am applying in Washington under the name of ________________________________________________ .

Last recorded place of caregiver employment ______________________________________________________ .

Starting and ending date of caregiver employment ________________________________________________

Start Date: mm/dd/yyyy

End Date: mm/dd/yyyy

Address __________________________________________________________________________________

Nurse Aide: Do not return this form to the Washington Nurse Aide Registry. After you have completed the

information requested above, it is your responsibility to send this form to the state agency from which

you completed your nurse aide training and testing.

Part II: To Be Completed By State Agency

 The information on this form is accurate and the above-named person is on the nursing assistant registry in

our state.

The above-named person is not on the nursing assistant registry in our state.



Date of Registration or Certification ________________________ Number ______________________________

Date of Expiration of Registration or Certification ___________________

mm/dd/yyyy

Has Registrant had any type of disciplinary action?  Yes  No

If yes, please explain: _______________________________________________________________________

_________________________________________________________________________________________

Is Registrant currently under investigation?  Yes  No

Signature _________________________________________________ Date __________________________

Title ______________________________________________________ State __________________________

DOH 667-005 May 2016

Forrm Doh 667-005 - Out Of State Credential Verification Form