Healthcare CNA Certification Form

HEALTHCARE CNA CERTIFICATION FORM

This form documents certification status, competency verification, health clearance, and background verification for the Certified Nursing Assistant (CNA) named below. Completion and signature attest to the accuracy of the information and authorize verification of training, immunizations, and background records as necessary for employment and regulatory compliance. Falsification of any information may subject the signer to disciplinary action, certification revocation, or legal penalties.

CNA PERSONAL INFORMATION

Date of birth:    Gender:    SSN (last 4 digits):

Relationship:    Phone:

CERTIFICATION & TRAINING DETAILS

Certificate number:    Date issued:    Expiration date:

Program completion date:    Total didactic & clinical hours:

EMPLOYING FACILITY

Supervisor name:    Title:    Phone:

COMPETENCY EVALUATION — CORE SKILLS

The evaluator must check "Verified" and enter the date and evaluator initials for each skill verified as competent in accordance with applicable state and facility standards. Skills not verified require remedial training prior to assignment.

Patient transfer, safe positioning & mechanical lift use — Verified date:   Initials:

Vital sign measurement and reporting — Verified date:   Initials:

Assistance with activities of daily living (ADLs) — Verified date:   Initials:

Infection prevention and standard precautions — Verified date:   Initials:

Assistance with medication administration (allowed scope) — Verified date:   Initials:

Basic wound care and pressure injury prevention — Verified date:   Initials:

Feeding, tube feeding assistance and aspiration precautions — Verified date:   Initials:

Documentation, reporting changes in condition and communication — Verified date:   Initials:

HEALTH CLEARANCE & BACKGROUND

TB screening: Date of most recent TB test:    Result (enter result):

Hepatitis B series completed:    Date (last dose or titer):

Influenza vaccination (current season):    Date:

COVID-19 vaccination series/status:    Date of last dose:

Tdap (most recent):    Date:

Background check completed:    Date completed:

CONTINUING EDUCATION & RECERTIFICATION

Continuing education hours completed within the past 24 months:    Date of last competency evaluation:

CERTIFICATION STATEMENT & AUTHORIZATION

I certify under penalty of law that the information provided on this form is true, complete, and correct to the best of my knowledge. I authorize the release of training records, immunization records, TB screening results, and background check information to the employing facility and to any state or licensing authority as required for certification verification. I understand that any material misrepresentation or omission may result in denial or revocation of certification or employment and may be subject to civil or criminal penalties.

I acknowledge my right to withdraw this authorization in writing; however, withdrawal will not affect disclosures already made in reliance on this authorization. This authorization expires on the date specified below or, if no date is entered, one year from the signature date.

Authorization expiration date:

I certify that the information on this form is accurate and I consent to verification as described above.

NOTICES

Privacy notice: Information collected on this form may include health information necessary to determine fitness for duty, comply with public health reporting obligations, and to meet facility policy and regulatory requirements. Records will be maintained in accordance with applicable privacy, employment, and public health laws.

Retention: Training and certification documentation will be retained for the period required by law and facility policy. Questions regarding this form should be directed to the employing facility's human resources or compliance office.

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