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State Registered Nurse Aide Challenge- Nursing Students Application

Complete this form in its entirety. The required skills check off list document may be found on this link: https://www.hdmaster.com/testing/cnatesting/kentucky/KY_CNA_Home.htm

Legal First Name

Middle

Legal Last Name

Birthdate

Phone

SSN

Gender

Male Female Other

Address

City

State

Zipcode

Section II

Are you currently listed on the Kentucky Nurse Aide Registry as active or inactive status?

What qualifications do you have to take the SRNA NATCEP Exam? (An official transcript, syllabus, course outline defining all 76 required nurse aide skills is required and must be less than one year from date of course completion) List the course(s) completed you feel qualifies you for the exam (Nursing Programs who require Nurse Aide training as a prerequisite DO NOT qualify for exam challenges):

Section III

Nursing School Attended:

Dates Attended:

Dean of Nursing:

Dean of Nursing Phone:

Dean of Nursing Email:

What best describes your situation. I have successfully completed:

Documents:

Transcript

Syllabus:

Course Outline:

Signed Skills Check Off List

Affidavit

I have attached ALL required documentation as requested for verification and my instructor has dated and initialed each required skill completed to determine eligibility to challenge the SRNA examination.

If approval to test is received, the exam fee of $115.00 and scheduling is handled through the TMU system.

By Submitting

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.