NATIONAL NURSE AIDE ASSESSMENT PROGRAM FOR OFFICE USE ONLY

ADMISSION APPLICATION † Fee Received

NORTH DAKOTA BOARD OF NURSING † DRP † Disc Rev
SFN 19034 (02-09) † Approval

*APPLICATION DIRECTIONS*
1. For initial testing attach $110 money order (for self pay candidates) or a $110 facility check (for those whose employer is paying). Initial
test applicants must choose either a written or an oral test and the skills test.
2. If you are retesting you will need to include the following appropriate fee:
Retesting both the written/oral and skills test: $110 money order or a $110 facility check
Retesting just the written or oral portion of the test: $45 money order or a $45 facility check
Retesting just the skills portion of the test: $65 money order or a $65 facility check
3. Complete this form and return it along with the appropriate fee to the ND Board of Nursing.
4. Once the North Dakota Board of Nursing receives and approves this completed application and fee, a confirmation notice will be sent to
you which will include the address of the test center, time of test, and items needed to take with you to the test site.
5. A No Show fee is charged to the applicant without a 24-hour cancellation of testing.

CANDIDATE INFORMATION (PLEASE PRINT)

Name (Last, First, MI) *Social Security Number Date of Birth

Mailing Address Home Telephone Number Work Telephone Number

City State Zip

TESTING INFORMATION
Have you completed a Nurse Aide training program? †No † Yes
If you answered “YES” please complete the name, city ,state, and date below:
Name of Nurse Aide training program

City State Date Completed

Please check the appropriate boxes † Initial testing - Written † or Oral † Skills †
† Retest - Written † or Oral † Skills †
Check which city you wish to test in † Bismarck † Devils Lake † Dickinson † Fargo †Jamestown †Williston
† Grafton † Grand Forks † Oakes † Mayville † Valley City † Minot
Date you would like to test (if known)

DEMOGRAPHIC INFORMATION (Optional)

Highest Level of Education Completed:
† Grade 7 or less † Grade 8 † Grade 9 † Grade 10 † Grade 11 † High School diploma/GED
† Two year college degree † Four year college degree
Primary Language:
Is English your primary language? † Yes † No
Gender: † Female † Male
Ethnicity:
† American Indian/Native Alaskan † Black/African American † White (non-Hispanic) † Asian American/Pacific Islander
† Hispanic † Other
Employment Status – How would you describe your work background?
† Currently working as a Nurse Aide
† Not currently working, but I HAVE worked as a Nurse Aide within the last two years
† Not currently working, and I HAVE NOT worked as a Nurse Aide within the last two years
† NEVER worked as a Nurse Aide
Nurse Aide Experience – How would you describe your history as a nurse aide?
† Less than six months
† Six months or more, but less than one year
† One year or more, but less than two years
† Two years or more, but less than three years
† Three years or more, but less than five years
† Five years or more

COMPLETE BOTH SIDES OF THIS APPLICATION Î

SFN 19034 (02-09)

ALL QUESTIONS MUST BE COMPLETED

1. Have you ever been arrested, charged, or convicted of a felony? (You must answer yes if the †YES †NO
felony arrest or felony charge resulted in a plea agreement, misdemeanor, nolo contendere,
deferred imposition, dismissal, or other action).
2. Have you had an unlicensed assistive person registry or nurse aide registry listing marked for †YES †NO
abuse, neglect, or misappropriation of property?
3. Has your registration or nursing license been sanctioned or disciplined by any other †YES †NO
jurisdiction?
4. Have you been investigated or are you presently being investigated by any other jurisdiction? †YES †NO

5. Have you been denied registration or nursing licensure by any other jurisdiction? †YES †NO

6. Have you been terminated from a nursing related job due to conduct that may be grounds for †YES †NO
disciplinary action?
7. Have you, in the last 2 years, been diagnosed with chemical dependency or participated in †YES †NO
chemical dependency treatment/rehabilitation?
You may answer “no” if you are currently participating in or have completed the Workplace
Impairment Program within the last 2 years for chemical dependency.
8. Have you, in the last 2 years, been diagnosed with or treated for a mental health or physical †YES †NO
condition which has adversely affected your ability to safely assist in the practice nursing?
You may answer “no” if you are currently participating in or have completed the Workplace
Impairment Program within the last 2 years for a mental health or physical condition.
If your answer is “YES” to any of the above questions, please attach a detailed written explanation (dates, places, charges, and
results) including any legal documents to the application and send to the Board of Nursing prior to testing for review.
I certify the information on this document is true and correct.
Signature Date

EMPLOYER VERIFICATION
™ If candidate is employed at a facility/agency requiring nurse assistant testing please have your employer complete the section below.
™ Candidates not employed do not need to complete this section.
Date
The candidate named above is eligible to take part in the National Nurse Aide Assessment Program.
Agency Name City State Zip

Address Sponsor Number

Agency Representative Signature Sponsor Fax Number Sponsor Telephone Number

As required by Federal Regulations, your name will be placed on the North Dakota State Department of Health Registry after successful
completion of the state approved competency evaluation test (NNAAP) and you will receive your CNA registry card from the North Dakota
Department of Health.

NORTH DAKOTA BOARD OF NURSING

919 S 7th STREET, SUITE 504
BISMARCK, ND 58504-5881
Telephone (701) 328-9788
Fax (701) 328-9785
Web Site www.ndbon.org

*In compliance with the Federal Privacy Act of 1974, the disclosure of the individual’s social security number on this form is mandatory pursuant to North Dakota
Century Code 43-50-02. The individual’s social security number is used for identification purposes.