Form Doh 667-034 - Nursing Assistant Expired Certification Activation Application (Page 6 of 9) in pdf

Form Doh 667-034 - Nursing Assistant Expired Certification Activation Application Page 6

2. Other License, Certification, or Registration

(Include Previous Credentials in Washington State)

Credential

Currently in Force

Method of

State/Jurisdiction

Profession

Credentialing

Yes

Number

Year Issued

Type

3. Professional Experience

End (mm/yyyy)

Type of experience of practice and location

Start (mm/yyyy)

4. Aids Education and Training Attestation

I certify I have completed the minimum of seven hours of education in the prevention, transmission

and treatment of AIDS. This includes the topics of etiology and epidemiology, testing and

counseling, infection control guidelines, clinical manifestations and treatment, legal and

ethical issues to include confidentiality, and psychosocial issues to include special population

considerations. I understand I must maintain records documenting said education for two years and

be prepared to submit those records to the department if requested.

I understand that should I provide any false information, my license may be denied, or if

issued, suspended or revoked. If AIDS education was included in your professional education or

training, an additional course is not required.

F School curriculum

Applicant’s Initials

Today’s Date

F Employer/Other

5. Disciplinary Action Attestation

I certify no action has been taken by any state or federal jurisdiction or hospital, which would prevent

or restrict my right to practice my profession.

I further certify I have not voluntarily given up any credential or privilege or have not been restricted in

the practice of my profession in lieu of or to avoid formal action.

Applicant’s Initials

Date

DOH 667-034 September 2016

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Form Doh 667-034 - Nursing Assistant Expired Certification Activation Application Page 6