New Jersey Office of the Attorney General Division of Consumer Affairs New Jersey Board of Nursing 124 Halsey Street, 6th Floor, P.O. Box 45010 Newark, New Jersey 07101 (973) 504-6430 www.NJConsumerAffairs.gov/nursing Homemaker-Home Health Aide Reinstatement Application Fees N.J.A.C. 13:37-5.5 Fee Schedule Licensure Reinstatement Fee Original License Issued In An Odd-Numbered Year Type of Fee License expired prior to: License expired on: November 30, 2015 November 30, 2015 Current biennial renewal fee $ 30.00 $ 30.00 Previous biennial renewal fee $ 30.00 0 Reinstatement fee $ 20.00 $ 20.00 Total $ 80.00 $ 50.00 Expiration date information is available on the Board of Nursing’s website under the online verification tab.
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New Jersey Office of the Attorney GeneralDivision of Consumer AffairsNew Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010Newark, New Jersey 07101
(973) 504-6430 www.NJConsumerAffairs.gov/nursing
Homemaker-Home Health AideReinstatement Application
FeesN.J.A.C. 13:37-5.5 Fee Schedule
Licensure Reinstatement Fee
Original License Issued In An Odd-Numbered Year
Type of Fee Licenseexpired prior to: Licenseexpired on: November30,2015 November30,2015
Criminal History Review for Certification Reinstatement
New Jersey Office of the Attorney GeneralDivision of Consumer AffairsNew Jersey Board of Nursing Criminal History Review Unit
ApplicAnt procedure
instruction sheet
homemAker - home heAlth Aideemployee criminAl history review
Pursuant toN.J.S.A.45:11-24.3et seq.,allapplicants for reinstatementofhomemaker-homehealthaidecertificationmustfirstsubmittoacriminal history record background check.TheBoardofNursingshallnotissueahomemaker-homehealthaidecertificatetoanyapplicantuntiltheBoarddeterminesthatnocriminalhistoryrecordinformationexistsonfilewiththeIdentificationDivisionoftheFederalBureauofInvestigation,orwiththeStateBureauofIdentificationoftheDivisionofStatePolice,whichwoulddisqualifythatpersonfrombeingcertified.
1. In order to complete the criminal history review process, youmust complete aCertification and Authorization formandobtain electronic fingerprinting.Theformsthatyouneedtoobtaintheelectronicfingerprinting,whichwillinitiatethecriminalhistoryrecordbackgroundcheck,willbeprovidedbytheBoardofNursing.However,itisyourresponsibilitytoscheduleanappointmentforthefingerprinting.
2. CompleteandhavenotarizedtheApplicationforCertificationasaHomemaker-HomeHealthAide,andtheCertification&AuthorizationformforaCriminalHistoryBackgroundCheck.Applicantsmustanswerall of the questions on theApplication forCertification as aHomemaker-HomeHealthAide and theCertification&Authorizationformtruthfullyandcompletely.
3. If youhavedisclosedonyourCertification&Authorization form that youhavebeen convictedof adisqualifyingoffense,youmustprovideevidenceofrehabilitation*alongwithyourapplication.
4. ReturnthecompletedCertification&Authorizationformintheenclosedenvelope.Yourfailuretoobtainthe electronicfingerprints is grounds for denial of your reinstatement application.Your reinstatementapplicationwill not be processed until the criminal history record background check has beencompleted.
*pleAse note:YouarerequiredtocompletetheapplicationformandtheCertification&Authorizationform, includinghavingyoursignaturewitnessedbyanotary.Failure toconsent to,orcooperate in, thesecuringofacriminalhistorybackgroundcheckautomaticallydisqualifiesyouforemployment.Pleasealsobeadvisedthatifyousubmitafalseswornstatement,youshallbedisqualifiedfromcertificationandshallnothaveanopportunitytoestablishrehabilitation.
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Note: All letters and documents which are used to substantiate rehabilitation must be signed by the individual who wrote the letter or document: for example, the employer, clergyman, probation officer, an official of a rehabilitation agency, or a counselor. Letters and documents that are not signed will not be considered by the Board of Nursing.
7. Your continuing responsibility to disclose convictions of disqualifying crimes/offenses:Youmust notifytheNew JerseyBoardofNursingwithinnomore thanfive(5)businessdays ifyouareconvictedofanyof thedisqualifying crimesoroffensesidentifiedonthenextfewpagesafterthisformhasleftyourhands.Failuretodosomayresultin automatic termination of your current employment, denial of an initial or renewal application for certification, revocation of your certification or conditional certification as a homemaker-home health aide and/or a fine of up to $1,000.
maybe;2. Thenatureandseriousnessoftheoffense;3. Thecircumstancesunderwhichtheoffenseoccurred;4. Thedateoftheoffense;5. Theageofthepersonwhentheoffensewascommitted;6. Whethertheoffensewasanisolatedorrepeatedincident;7. Anysocialconditionswhichmayhavecontributedtotheoffense;and8. Any evidence of rehabilitation, including good conduct in prison or in the community, counseling or
psychiatric treatment received, acquisition of additional academic or vocational schooling, successfulparticipation incorrectionalwork-releaseprograms,or therecommendationof thosewhohavehad thepersonundertheirsupervision.
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disquAliFying crimesCrimes set Forth in n.J.s. 2c thAt disquAliFy An ApplicAnt
N.J.S.2C:12-1etseq.,N.J.S.2C:13-1etseq.,N.J.S.2C:14-1etseq.,orN.J.S.2C:15-1etseq.;or(b) against the family, children, or incompetents,meaning those crimes and disorderly persons offenses set forth in
7. Checkonly onebox: Ihaveno record of conviction forany ofthedisqualifyingcrimesoroffensesidentifiedonthepreviouspage. Ihavebeenconvictedofoneormoreofthedisqualifyingcrimesoroffensesidentifiedonthepreviouspage. Every such conviction on record must be disclosed. Truecopiesofeachjudgmentofconviction,sentencingorderand
terminationofprobationorder,ifapplicable,must besubmittedwiththisform.Anydocuments(includingemployerorsupervisorlettersofreference,ifapplicable)whichpresentclearandconvincingevidenceofrehabilitationmust besubmittedwiththisform.Failure to follow these instructions may result in automatic termination of your current employment, denial of an initial or reinstatement application as a homemaker-home health aide, revocation of certification or conditional certification and/or a fine of up to $1,000.
Your continuing responsibility to disclose convictions of disqualifying crimes/offenses:Youmust notifytheNewJerseyBoardofNursingwithinnomorethanfive(5)businessdaysifyouareconvictedofanyofthedisqualifyingcrimesoroffensesidentifiedonthepreviouspageafterthisformhasleftyourhands.Failuretodosomayresultinautomatic termination of your current employment, denial of an initial or reinstatement application for certification, revocation of your certification or conditional certification as a homemaker-home health aide and/or a fine of up to $1,000.
You must immediately inform the New Jersey Board of Nursing in writing of any address change. A name change requires the submission of legal documentation.
AFFidAvit
This affidavit is to be executed by the applicant before a notary public:
New Jersey Office of the Attorney GeneralDivision of Consumer AffairsNew Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010Newark, New Jersey 07101
(973) 504-6430 www.NJConsumerAffairs.gov/nursing
ApplicAtion for reinstAtement of new Jersey
HomemAker-Home HeAltH Aide certificAte
you mAy not prActice in tHe stAte of new Jersey until your HomemAker-Home HeAltH Aide certificAte is reinstAted.
Please print in black or blue ink only. This application must be completed, notarized and returned to the New Jersey Board of Nursing with your reinstatement fee payable by check or money order. Please be advised that the application fee is nonrefundable. The certification fee is refundable. Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act (OPRA).
Complete the following information:
Full Name __________________________________________________________________________
City, State, ZIP ______________________________________________________________________ Telephone number(s) __________________________ ___________________________________ (Home) (Work)
Date of Birth __ __ /__ __ /__ __ Certificate number _____________________________________ Month Day Year
If you are a U.S. - born citizen, please submit your birth certificate. If you are a foreign-born/naturalized U.S. citizen, please submit your birth certificate (English translation, if applicable) AND a U.S. passport OR certificate of naturalization.
Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of licensure or certification.
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7,60.8 and 60.9, the Board or Committee is required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care professionals.
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Attach a clear, full-face passport-style photograph (2˝x 2˝) of your head and shoulders, taken withinthe past six months, with your name printed on the back of the photo. A photo is required with each application.
Areyouindefaultinregardtoanystudentloanobligation(s)? Yes No
If “Yes,” youmust obtain documentary evidence that you have reached an arrangementwith the bank orwith the entity that issued your student loan, for the eventual repayment of the loan.Youwill not be able to obtain a licenseorcertificateunlessyouprovidetherequireddocumentsconcerningtheplanforrepaymentofyourstudentloan.
ChildSupport
Pleasecertify,underpenaltyofperjury,thefollowing:
a. Doyoucurrentlyhaveachild-supportobligation? Yes No
(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No
“Ability to practice as a certified homemaker-home health aide”istobeconstruedtoincludeallofthefollowing:
a. Thecognitivecapacitytoexercisereasonablehomemaker-homehealthcarejudgmentsandtolearnandkeepabreastofprofessionaldevelopments;and
b. Theabilitytocommunicatethosejudgmentsandrelatedinformationtopatientsandotherinterestedparties,withorwithouttheuseofaidsordevices,suchasvoiceamplifiers;and
c. Thephysicalcapabilitytoperformthedutiesofahomemaker-homehealthaide,withorwithouttheuseofaidsordevices,suchascorrectivelensesorhearingaids.
“Chemical substance” is tobeconstrued to includealcohol,drugsormedications, including those takenpursuant toavalidprescriptionforlegitimatemedicalpurposesandinaccordancewiththeprescriber’sdirection,aswellasthoseusedillegally.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g.heroinorcocaine)aswellastheuseofcontrolleddangeroussubstanceswhicharenotobtainedpursuanttoavalidprescriptionornottakeninaccordancewiththedirectionsofalicensedhealthcarepractitioner.
a. Doyouhaveamedicalconditionwhichinanywayimpairsorlimitsyourabilitytopracticeyourprofessionwithreasonableskillandsafety? Yes No
b. Are the limitationsor impairmentscausedbyyourmedicalconditionreducedoramelioratedbecauseyoureceiveongoingtreatment(withorwithoutmedications)orparticipateinamonitoringprogram**?
Yes No Notapplicablec. Arethelimitationsorimpairmentscausedbyyourmedicalconditionreducedoramelioratedbecauseofthefieldofpractice,
thesettingormannerinwhichyouhavechosentopractice? Yes No Notapplicabled. Doesyouruseofchemicalsubstance(s)inanywayimpairorlimityourabilitytopracticeyourprofessionwithreasonableskill
andsafety? Yes No Notapplicablee. Haveyoueverbeendiagnosedashavingorhaveyoueverbeentreatedforpedophilia,exhibitionismorvoyeurism?
New Jersey Office of the Attorney GeneralDivision of Consumer AffairsNew Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010Newark, New Jersey 07101
(973) 504-6430 www.NJConsumerAffairs.gov/nursing
Employment Certification for the Reinstatement of a Lapsed Certification Directions: Please complete this certification. Have it notarized and return it to the New Jersey Board of Nursing. If you have had more than two employers, please add additional sheets of paper with the employment data. The Board may contact your employer(s) to verify your employment.
____________________________________________________________________________ First name Middle name Last name Maiden name
____________________________________________________________________________ Present Street Address City State ZIP Code
Employment Data: (For the past five (5) years in New Jersey or in any other jurisdiction.)
1. _________________________________________________________________________ Name of employing agency or facility
_________________________________________________________________________ Street address
_________________________________________________________________________ City State ZIP Code
_________________________________________________________________________ Job Title Employment Dates: From To
_________________________________________________________________________ Supervisor’s name Title Telephone No. (include area code)
Are you currently working as a home health aide (H.H.A.), or did you work as an H.H.A. while your certification was lapsed or expired?
Yes No
Provide an explanation: ______________________________________________________
Did you work as a H.H.A. while your certification was inactive?
Yes No
Provide an explanation: ______________________________________________________
Were you terminated or asked to resign?
Yes No
Provide an explanation: ______________________________________________________
2. _________________________________________________________________________ Name of employing agency or facility
_________________________________________________________________________ Street address
_________________________________________________________________________ City State ZIP Code
_________________________________________________________________________ Job Title Employment Dates: From To
_________________________________________________________________________ Supervisor’s name Title Telephone No. (include area code)
The person whose signature appears below personally appeared before me and, being duly sworn, says that he/she is the person referred to in the foregoing Employment Certification. The home health aide further attests that he/she has read and understands this certification and that all of the information contained herein is provided completely and truthfully to the best of his/her knowledge and beliefs.
____________________________________ Signature of applicant
Sworn and subscribed to before me this _________
day of _______________________ , ___________ Month Year
_________________________________________ Name of Notary Public (please print)
_________________________________________ Signature of Notary Public
