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Nurse Aide

Applications, Forms & Fees

Applicant Forms

  • Application – there is none for nurse aides
  • Fees – there is none for nurse aides
  • Interstate Endorsement – Complete this form if you are a nurse aide in another state and transferring/moving to Nebraska and want to work in Nebraska.

  • Employment Verification Form –submit employment information when working private duty or out-of-state employment.
  • Name Change/License Reissue Form – There is no charge for nurse aides changing their name. Attach to the form a copy of the document that proves your name change.
  • Address Change


Facility Forms
  • Registry Form – To be submitted by the facility employer upon hire of a nurse aide.

  • End of Employment/Termination Form – submitted by employer when nurse aide no longer works for them

  • List/roster of nurse aides working for an employer – list of nurse aides presently employed at a specific setting according to the nurse aide registry
    • updated weekly on Friday
    • Search alpha to city, then alpha to employer, than alpha to nurse aide’s last name
    • Search and print the individual facility’s list carefully as it is over 1100 pages
    • May use for submission of end of employment/termination information
  • Abuse In-Service training – to be used for documentation by the employer or college of completion of the training for a nurse aide transferring to Nebraska from another state.

Documents in PDF PDF format require the use of Adobe Acrobat Reader
which can be downloaded for free from Adobe Systems, Inc.
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