DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance
F-03211 (02/2024)
STATE OF WISCONSIN
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WISCONSIN NURSE AIDE REGISTRY RENEWAL FORM
Federal and state regulations require that you performed nursing or nursing-related services for pay, under the supervision of a RN
or LPN, during and since your last 24-month certification period.
Only use this form if your employer is not listed as an eligible employer in your TMU account.
Instructions
• Section I – Nurse Aide Information: The nurse aide must complete this section of the form. Next, complete Section II or
Section III.
• Section II – Employer Information (Facility/Provider): The actual designated representative of the facility/provider where work
was performed must complete this section of the form.
• Section III – Renewal via Out of State Reciprocity: Renew your Wisconsin certification via active, out of state registry status.
• Return the completed forms via fax or email to: 608-226-5524 or dhswidqa_natcep@dhs.wisconsin.gov
Contact Information
If you need assistance, call 608-261-9315 or email dhswidqa_natc[email protected]isconsin.gov
Section I – Nurse Aide Information
The nurse aide must complete this section of the form.
Last Name First Name M.I.
WI CNA Number Previously Used Last Names (if applicable)
Address City State ZIP Code
Phone Number Email
Attestation
I attest, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that
knowingly providing false information or omitting information may result in denial of licensure, a fine of up to $10,000, or
imprisonment not to exceed six years or both (Wis. Stat. § 946.32).
Nurse Aide Signature Date
Section II – Employer Information (Facility/Provider)
The actual designated representative of the facility/provider where work was performed must complete this section of the form.
Facility/Provider Contact Name
Facility/Provider Name Employer Phone Number
Address City State ZIP Code
Employer Type Employer Email
I certify that the nurse aide named above is/was employed by this facility as a nurse aide and performed nurse aide services for
monetary compensation under the supervision of an RN or LPN during the time period from:
Date to Date
The total hours this person was employed as a CNA during this period are hours.
Attestation
I attest, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that
knowingly providing false information or omitting information may result in denial of licensure, a fine of up to $10,000, or
imprisonment not to exceed six years or both (Wis. Stat. § 946.32).
Facility/Provider Designated Signature Title
Date
F-03211 (02/2024) Page 2 of 2
Section III – Renew via Out of State Reciprocity (active status on another state’s nurse aide registry)
State
Certification Number
Lapse Date
Common Questions
• I worked in a private home as a CNA. Will these hours count?
Employment hours in a private setting will not be counted unless the work is performed under the supervision of a licensed
nurse.
• Can I submit paystubs or a letter from my employer to verify my employment hours?
Paystubs or letters from employers will not be accepted to verify the number of employment hours. The employment verification
form must be completed and submitted.
• Can I change the dates on the form?
Forms with altered dates will not be accepted. The dates listed are not specific employment dates. Only the number of hours
worked within the specified timeframe should be reported in Section II.
• How do I find out my nurse aide certification status or my last date of certification?
Please visit the registry website: https://wi.tmutest.com/ to look up your registry account and determine your certification status.
• When can I renew my certification?
Your nurse aide certification may be renewed within 90 days of the certification lapse date. It is possible you may have your
certification renewed retroactively with employment verification.
• How long does it take to process my certification renewal request.
Renewal requests are processed in the order they are received. You can check the status of your certification the Wisconsin
nurse aide registry website: https://wi.tmutest.com/.
