To submit this form, please mail it to Prometric, Attn: MA Nurse Aide Registry Recertification, 7941 Corporate Drive, Nottingham, MD 21236. You may also contact your employer for additional submission options. Make sure to submit your application at least 30 days prior to your certification expiration to avoid lapses.

Keep in mind that renewal submissions should ideally be submitted at least 30 days prior to your expiration date. Important deadlines for 2024 will reflect any specific guidance from the Massachusetts Nurse Aide Registry. For 2025, continue to monitor the registry for updated submission timelines.

The purpose of this form is to allow nurse aides to maintain their certification within Massachusetts. It serves as a formal request for recertification, ensuring that all required information is accurately provided. Submitting this form timely helps uphold the standards of care in the healthcare system.

• 1. Name: The full legal name of the nurse aide completing the form.
• 2. Social Security: The social security number must be provided for identification.
• 3. Address: The current residential address of the nurse aide.
• 4. Employer Name: The name of the current or most recent employer.
• 5. Date of Hire: The date when the nurse aide began working for the current or last employer.
• 6. Date of Termination: The date when the nurse aide left their previous employment, if applicable.
• 7. Employer Signature: The signature of the employer confirming the employment details.

Failure to submit this form can lead to a lapse in your certification status. This means you will not be eligible to work as a nurse aide until your certification is renewed. It may also require additional steps, including retaking necessary tests.

• Certification Lapse: Your certification may become inactive, impacting your employment eligibility.
• Retesting Requirement: You may be required to retake the knowledge and clinical skills tests to regain certification.
• Employer Verification Delays: Delays in employer verification and paperwork can hinder your recertification process.

• 1. Renewal Application: Complete this form to renew your nurse aide certification before it expires.
• 2. Change of Name: Submit this form if your legal name has changed since your last application.
• 3. Change of Employment: Notify the registry about new employment information using this form.