Oklahoma State Department of Health
Nurse Aide Registry (NAR)
PO Box 268816
Oklahoma City, OK 73126-816
p.
405 426
-8150
Oklahoma State Department of Health
Protective Health Services
ODH Form 717
Revised 5/2/2022
Recertification Application
Section 3 - Personal Information
First MI
Last
**If you have had a name change since your last renewal, please include a certified copy of the marriage license or other court
document which reflects the change of name when you submit this application.**
Current Mailing Address
City State
Zip
E-mail address Telephone Number
Section 5 – Affirmation - I affirm the information on this form to be true and correct to the best of my knowledge.
Signature of Nurse Aide
Date
Name of most recent Facility/Agency where employed – Phone
LTC Renewal only - NO Fee required: Email: [email protected]k.gov, Fax: 405-900-7572 or Mail: PO Box 268816, Oklahoma City, OK 73126-8816
R
enewal(s) Requiring Fee(s): Make check/money order payable to: OSDH/Nurse Aide Registry
Mail to: NAR-OSDH, P. O. Box 268816, Oklahoma City, OK 73126-8816
NOTE: All Fees submitted are NON-Refundable Total Enclosed $_
_____
Section 1 - Check the type(s) of Nurse Aide Certification(s) you want to renew.
☐Renew LTC – No Fee Required ☐ Renew HHA - $10 Fee ☐ Renew DDDCA - $10 Fee ☐ Renew RCA - $10 Fee Renew ADC - $10 Fee
☐ Renewing Feeding Assistant (FA) - $10 (8 hours paid work proof as a FA or 8 hours training proof per OAC 310:675-19-3)
X
/ /
☐Renew CMA - $10
☐Attach documentation of continuing education equivalent to eight (8) hours for every twelve months of certification, excluding
the first year of
certification.
**Continuing Education Units (CEUs) must be completed during the certification period or within one year after that.
***Advanced CMA certifications will be renewed at the same time as your CMA renewal. If you are requesting a new advanced
CMA certification,
please include the $10 fee for each one requested with the Advanced Training Application received from the course
instructor.
/ /
Section 4 – Employment Verification – Must submit proof of 8 hours paid work in nursing or nursing related services during the 24
month certification time frame. **No Private Duty**
☐
Administrative Signature OR
☐
Paystub OR
☐
Form W-2
Facility Name
Address City, State, Zip Code Phone Number
/ / - /
/
Aide
is still employed:
☐
Yes
☐
No
X
Administrative/HR Signature
Start Date End Date
___/___/___
Date of Birth
_______/_______/_______
Social Security Number
Oklahoma State Department of Health
Nurse Aide Registry (NAR)
PO Box 268816
Oklahoma City, OK 73126-816
p.
405 426
-8150
Oklahoma State Department of Health
Protective Health Services
ODH Form 717
Revised 5/2/2022
INSTRUCTIONS FOR RECERTIFICATION APPLICATION
ODH FORM 717
S
ection 1: Check the type of Nurse Aide Certification(s) you want to renew
Please make sure you check all types of certifications you want to renew. If you send in a fee for your Home Health Aide (HHA)
renewal and also have a Long Term Care certification expiring at the same time or within a few months of each other, they will
both
be automatically renewed.
Section 2: Certified Medication Aide – Renewal - Chapter 677-13-1(d) General Requirements
*Please provide a copy of your certificate showing completion of at least eight (8) hours of continuing education units (CEUs)
within
the last twelve (12) months of your certification, excluding the first year renewal of certification. Classroom and supervised
practical
training hours completed by a CMA in a Department-approved advanced training program may be used in place of the
CEUs to renew your certification so long as the advanced training is at least 8 hours.
*You must have a current certification as a Long Term Care Aide (LTCA), Home Health Aide (HHA), or Developmentally
Disabled
Direct Care Aide (DDCA) to renew your CMA certification.
Section 3: Personal Information
*Fill out your date of birth, social security number, and full name.
*Notification of change of name shall require certified copies of a marriage license or other court document which reflects the
change of nam
e.
* Fill out the Current Mailing Address – be sure to include Lot or Apartment number
Change of Law – Starting November 1, 2015: Notice of change of address or telephone number shall be made within ten (10)
days
of the effected change. Notice shall not be accepted over the phone. Title 63.O.S., Section 1-1951(A)(7),(D)(3)(b) and
(D)(8)
*Fill out the e-mail address and/or telephone number. If there are problems with your Recertification Application we will e-mail a
problem l
etter. If you do not have an e-mail address we will contact you by phone or mail to let you know what is wrong.
Section 4: Employment Verification - Chapter 677-5-2(d)(2)
* Provide documentation of at least eight (8) hours of nursing or health related services for compensation (paid work) during the
preceding 24
months of your certification (other than CMA).
*Employment worked in private duty where there is no overseeing doctor or nurse WILL NOT be allowed to renew your certification.
*The Administrator, Director, Supervisor, or HR Representative must fill out the dates you worked (or began work to “present”)
and
sign the Recertification Application if you are not including a paystub or Form W-2. If using a paystub or Form W-2,
please fill out
the dates you worked or the date you started to work to “Present” if you are still working.
Section 5: Affirmation
*Please make sure your name is printed clearly and you have signed the application. The application will not be processed
if it is
not signed.
C
ertification status may be checked 24 hours a day online at: http://nar.health.ok.gov
CHECK LIST TO COMPLETE THE RECERTIFICATION PROCESS
□ Do you have a Tax Hold on your account by the OK Tax Commission (OTC)? Please send in your application even if
you have a Tax Hold so it is pending the Tax Hold being lifted. Contact OTC at 1-800-522-8165 or (405) 522-6800 if
you have a Tax Hold. The OTC will e-mail the Nurse Aide Registry when the “Hold” is lifted.
□ If renewing your CMA certification and it is not your first renewal – include the certificate of completion of at least
eight (8) hours of continuing education units with your renewal (every twelve (12) months).
□ Include 8 hours of work proof (excluding CMA renewals) during your certification period this can be: (1) signature of
theAdministrator, Director, Supervisor, or HR Representative in Section 4 OR (2) a copy of your pay stub OR (3)
the Form W-2 from your employer that you filed with your taxes
□ The Affidavit of Lawful Presence is complete. If you are a Qualified Alien, you must provide a copy (front and
back) of what authorizes you to work in the USA. You must print and sign your name on the Affidavit. Please print
clearly.
□ Be sure your name is printed clearly and you have signed the application (Section 5).
□ Include the fee for the renewal of your certification, if required.
Oklahoma State Department of Health ODH Form 301
Protective Health Services Revised 5/2/2022
Oklahoma State Department of Health
Nurse Aide Registry (NAR)
PO Box 268816
Oklahoma City OK 73126-8816
p. 405 426-8150
AFFIDAVIT OF LAWFUL PRESENCE BY PERSON
MAKING APPLICATION FOR A LICENSE, PERMIT OR CERTIFICATE
I, the undersigned applicant, being of lawful age, state that one of the following statements is true and correct: (Check
which of the following statements apply.)
I am a United States citizen.
OR
I am an approved alien under the federal Immigration and Nationality Act and am approved to be present in the United
States. I understand that this approval may or may not include approval for employment. The issuance of a
license, permit, or certificate issued by the Oklahoma State Department of Health is not authorization for
employment in the United States.
Write the identification number and the name of the authorizing document below.
Admission/Registration #:
Authorizing Document: ______
I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct and that I have
read and understand this form and executed it in my own hand.
Date
City & State
Signature
Print Name
If applying to renew a license, permit, or certificate, please write the number: ___________________________________
Current license, permit, or certificate #
INSTRUCTIONS FOR USE OF THE AFFIDAVIT OF LAWFUL PRESENCE BY
PERSON MAKING APPLICATION FOR A LICENSE, PERMIT OR CERTIFICATE
The person signing this form must read these instructions carefully.
1. If the person signing this form is receiving services and not making an application for a license, permit or certificate, this
form should not be used but rather, either the form titled, “Affidavit of Lawful Presence by Parent or Guardian of Person
Receiving Services” or the form titled “Affidavit of Lawful Presence by Person Receiving Services” should be used.
2. If the person signing this form is a citizen of the United States then that person should check the box to the left of the
statement, “I am a citizen of the United States.” If the person signing this form is not a citizen of the United States but is an
approved alien under the federal Immigration and Nationality Act and is lawfully present in the United States then that person
should check the box to the left of the statement, “I am an approved alien under the federal Immigration and Nationality Act
and am approved to be present in the United States.”
3. Write the identification number in the space provided after “Admission/Registration #” and write the name of the
authorizing document in the space provided after Authorizing Document. For example, INS Form I-551 or INS Form I-94.
4. The person signing this form should write today’s date in the space provided; write the city and state where they are
located when they sign this form; sign their name in the space provided for signature; and print their name in the space
provided. If applying for a renewal, write the license, permit, or certificate number in the space provided.
5. Within this form, the term “penalty of perjury” means the willful assertion of the fact of either United States citizenship
or lawful presence in the United States as a qualified alien, and made upon one’s oath or affirmation and knowing such
assertion to be false. Making such a willful assertion on this form knowing it to be false is a crime in Oklahoma and may be
punishable by a term of incarceration of not more than five (5) years in prison. Additionally, one who procures another to
commit perjury is guilty of the crime of subornation of perjury and may be punished in the same manner, as he would be if
personally guilty of the perjury so procured.
Oklahoma State Department of Health
Protective Health Services
ODH Form 301
Revised 5/2/2022
Oklahoma State Department of Health
Nurse Aide Registry (NAR)
PO Box 268816
Oklahoma City, OK 73126-8816
p. 405 426-8150
Procedure for Initial License/Certification Applications
The Oklahoma State Department of Health (OSDH) participates in the Systematic Alien Verification for
Entitlements (SAVE) Program, which is an intergovernmental information-sharing initiative designed to
aid in determining a non-citizen applicant's immigration status (lawful presence), and thereby ensuring
only U.S Citizens and eligible non-citizens receive government benefits, such as licenses. OSDH may
only issue licenses, certifications or permits to Qualified Aliens (non-U.S. citizens) who present valid
documentary evidence of one (1) of the following:
Alien Lawfully Admitted for Permanent Residence:
• INS Form I-551 (Alien Registration Receipt Card, commonly
known as a “green card”); or
• Unexpired Temporary I-551(Stamp in foreign passport or on
INS Form I-94).
Immigrant or Non-Immigrant Visa Status:
• INS Form I-94
• INS Form I-688B
Asylee:
• INS Form I-94 annotated with stamp showing grant of asylum
under §208 of the INA;
• INS Form I-688B (Employment Authorization Card)
annotated “27a .12 (a) (5)”;
• INS Form I-766 (Employment Authorization Document)
annotated “AS”;
• Grant letter from the Asylum Office of INS; or
• Order of an immigration judge granting asylum.
Refugee:
• INS Form I-94 annotated with stamp showing admission
under §207 of the INA;
• INS Form I-688B (Employment Authorization Card)
annotated “274 a.12 (a) (3)”;
• INS Form I-766 (Employment Authorization Document)
annotated “A3”; or
• INS Form I-571 (Refugee Travel Document).
Alien Who Has Been Battered or Subjected to Extreme
Cruelty:
INS petition and appropriate supporting documentation
Alien Paroled Into the U.S. for a least One Year:
• INS Form I-94 with stamp showing admission for at least one
year under §212 (d) (5) of the INA. (Applicant cannot
aggregate periods of admission for less than one year to meet
the one-year requirement.)
Alien Whose Deportation or Removal Was Withheld:
• INS Form I-688B (Employment Authorization Card)
annotated “274 a.12 (a) (10)”;
• INS Form I-766 (Employment Authorization Document)
annotated “A10”; or
• Order from an immigration judge showing deportation
withheld under §243 (h) of the INA as in effect prior to April 1,
1997, or removal withheld under §241 (b) (3) of the INA.
Alien Granted Conditional Entry:
• INS Form I-94 with stamp showing admission under §203 (a)
(7) of the INA;
• INS Form I-688B (Employment Authorization Card)
annotated “274 a.12 (a) (3)”; or
• INS Form I-766 (Employment Authorization Document)
annotated “A3”.
Cuban/Haitian Entrant:
• INS Form I-551 (Alien Registration Receipt Card, commonly
known as a “green card”) with the code CU6, CU7, or CH6;
• Unexpired temporary I-551 stamp in foreign passport or on
INS Form I-94 with the code CU6 or CU7; or
• INS Form I-94 with stamp showing parole as “Cuba/Haitian
Entrant” under § 212 (d) (5) of the INA.
Qualified Aliens: State law requires the Oklahoma State Department of Health to verify the immigration
status (lawful presence) of all non-U.S. citizens upon initial license/certification and renewal.
QUALIFIED ALIENS MUST ATTACH A COPY(FRONT & BACK) OF THE DOCUMENTS that supports
their status as shown above with their Affidavit of Lawful Presence. A license, permit, or certification will not be
issued until the appropriate documentation is submitted.
Renewal applicants with new immigration documents are required to mail the new immigration
documentation listed above to establish eligibility for renewal.
U.S. Citizens: After receipt of this Affidavit of Lawful Presence, U.S. Citizens are not required to attach
an Affidavit of Lawful Presence every year.