Certified Nursing Assistant Fingerprinting Requirements

ARIZONA STATE BOARD OF NURSING (AzBN)

CERTIFIED NURSING ASSISTANT

EXAM APPLICATION INSTRUCTIONS

REQUIREMENTS FOR CERTIFICATION IN ARIZONA

  • Complete test application for Certified Nursing Assistant Examination – Mail to D&S Diversified.
    Print out application by going to
    www.hdmaster.com/testing/cnatesting/arizona/ azformpages/azforms/1101AZ.pdf and azforms/1402AZ.pdf.
  • Pass the written and manual tests. (This should be done before you send an application to AzBN.
  • Complete the AZBN application for Certified Nursing Assistant certification – Mail to Arizona State Board of Nursing (AZBN).
  • Complete a fingerprint card (see fingerprinting below).
  • Pay exam fees (optional).
  • Fingerprint results – If the results of your fingerprint check show a positive criminal history, an investigation will be started and certification will not be given to you until the investigation is done. This may take 4 to 6 months.
  • Include with your application:

a. A completed fingerprint card AND

b. A copy of the “certificate of completion” of a nursing assistant program that Arizona State Board of Nursing has approved OR

c. Proof of completing a 120 hour nursing assistant program approved by another state / territory OR

d. Proof of completing a 75 hour nursing assistant program approved by another state / territory AND

Proof of working as a nursing assistant for an additional 45 hours OR

e. Proof of graduation from an approved RN or LPN program or holds a valid RN/LPN license or meets educational requirements

for RN/LPN licensure in Arizona

NOTE: Applicants who have not taken the CNA exam within 2 years of their training and can show proof that they worked as a nursing

assistant for 160 hours every 2 years, since they completed a state approved nursing assistant program, may take the CNA test.

Example: An applicant took their initial training in 2007 and never took the exam, needs to show they worked 160 hours

between 2007 & 2009, and 160 hours between 2009 & 2011. This may be validated in a letter signed by the employer.

FEES

  • There are no required fees.
  • Optional fee of $50 for wallet size, pink-colored paper certificate. If the $50 is not included with your application, the Board will assume you do not want a documen
  • Optional fee of $50 to have your fingerprint card processed before passing your CNA written & manual skills test
  • Do not send cash. You may send a money order or check. All personal checks must be pre-printed with your name and address and made payable to the Arizona State Board of Nursing. Purchase Orders from facilities are not accepted.
  • All fees are non-refundable. A $50 fee will be charged for checks returned because of insufficient funds.

CITIZENSHIP/NATIONALITY/ALIEN STATUS DOCUMENTATION

  • Federal law, 8 U.S.C. § 1641, and State law, A.R.S. § 1-501, require documentation of citizenship or nationality for certification. If the documentation does not demonstrate that the applicant is a United States citizen, national, or a person described in specific categories, the applicant will not be eligible for certification in Arizona. All applicants must submit documentation regarding their citizenship/nationality/alien status with their application. See attached list A & B for specific documentation required.

FINGERPRINTING


According to A.R.S. § 32-1606(B) (16), each applicant for initial licensure or certification is required to submit a full set of

fingerprints. If you have not submitted a fingerprint card with your application, one will be mailed to you after we receive your

application. It is important for you to use that specific fingerprint card because we have Arizona State Board of Nursing information

printed on the card. It can take 3 to 4 weeks to receive fingerprint results. You will not be certified until results are received. A

copy of a fingerprint clearance card cannot be substituted for this requirement.

 

FELONY CONVICTIONS

 

According to A.R.S. § 32-1606(B), an applicant for certified nursing assistant is not eligible for certification if the applicant has any

felony convictions and has not received an absolute discharge from the sentences for all felony convictions. The absolute discharge

from the sentence for all felony conviction(s) must be received 5 or more years before submitting this application. If you cannot

prove that the absolute discharge date is 5 or more years, the Board will notify you that you do not meet the requirements for

certification.


For more information, regarding time frames for nursing assistant certification, consult A.A.C. RC-19-102. For assistance

with the application process, contact Helen Tay at (602) 771-7800. If you fail to respond to a deficiency notice or

comprehensive written request within the applicable time periods, your application will be withdrawn. If you are still

interested in nursing assistant certification, you must submit a new application and applicable fees.

To obtain an application for CNA Exam, go to our website and download an application www.azbn.gov

Arizona State Board of Nursing, 4747 N 7th St, Suite 200, Phoenix, AZ 85014-3655

 

YOUR FINAL CHECKLIST

 

You have enclosed a copy of a document as proof of citizenship/nationality/alien status

You have enclosed a copy of certificate of completion from CNA program stating number of hours of CNA course

You have enclosed a copy of letter from D & S Diversified showing you passed the written & skills CNA Exam

You have enclosed a completed fingerprint card

You answered ALL QUESTIONS

You signed the application

Your application is in black ink

1

ARIZONA STATEMENT OF CITIZENSHIP & ALIEN STATUS

All applicants must answer questions on the application regarding citizenship. A Xeroxed copy of a document that shows evidence

of your citizenship or alien status MUST BE submitted with your application for licensure or renewal. See List A or List B.

LIST A

Evidence showing U.S. citizen or U.S. national status includes the following:

*If any of the following documents do not contain a photograph of the individual, the individual shall also present a

government issued document that contains a photograph of the individual.

a. Primary Evidence:

(1) An AZ driver’s license issued after 1996 or an AZ non-operating identification license

(2) A birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (on or after January 13,

1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, or the Northern Mariana Islands

(on or after November 4, 1986, Northern Mariana Islands local time) (unless the applicant was born to foreign diplomats

residing in such a jurisdiction); *

(3) A birth certificate or delayed birth certificate issued in any state, territory or possession of the U.S.; *

(4) A signed United States passport; current or expired;

(5) Report of birth abroad of a U.S. citizen (FS-240) (issued by the Department of State to U.S. citizens); A U.S. certificate of

birth abroad *

(6) Certificate of Birth (FS-545) (issued by a foreign service post) or Certification of Report of Birth (DS-1350), copies of

which are available from the Department of State; *

(7) Form N-550 or N-570, Certificate of Naturalization (issued by the Service through a Federal or State court, or through

administrative naturalization after December 1990 to individuals who are individually naturalized; the N-570 is a

replacement certificate issued when the N-550 has been lost or mutilated or the individual’s name has changed);

(8) Form N-561, Certificate of Citizenship;

(9) Form I-197, United States Citizen Identification Card (issued by the Service until April 7, 1983 to U.S. citizens living near

the Canadian or Mexican border who needed it for frequent border crossings) (formerly Form I-179, last issued in February

1974);

(10) Form I-873 (or prior versions), Northern Marianas Card (issued by the Service to a collectively naturalized U.S. citizen

who was born in the Northern Mariana Islands before November 3, 1986);

(11) Statement provided by a U.S. consular official certifying that the individual is a U.S. citizen (given to an individual born

outside the United states who derives citizenship through a parent but does not have a FS-240, FS-545, or DS-1350); or *

(12) Form I-872 (or prior versions), American Indian Card with a classification code “KIC” and a statement on the back

identifying the bearer as a U.S. citizen (issued by the Service to U.S. citizen members of the Texas Band of Kickapoo

living near the U.S./Mexican border).

(13) A tribal certificate of Indian blood.*

(14) A tribal or bureau of Indian affairs affidavit of birth*

NOTE: SOCIAL SECURITY CARDS ARE NOT ACCEPTABLE DOCUMENTATION.

b. Secondary Evidence

If the applicant cannot present one of the documents listed in (a) above, the following may be relied upon to establish U.S.

citizenship or U.S. national status;

(1) Religious record recorded in one of the 50 states, the District of Columbia, Puerto Rico (on or after January 13, 1941),

Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, or the Northern Mariana Islands (on or

after November 4, 1986, Northern Mariana Islands local time) (unless the applicant was born to foreign diplomats residing

in such a jurisdiction) within three 3 months after birth showing that the birth occurred in such jurisdiction and the date of

birth or the individual’s age at the time the record was made;

(2) Evidence of civil service employment by the U.S. government before June 1, 1976;

(3) Early school records (preferably from the first school) showing the date of admission to the school, the applicant’s date and

U.S. place of birth, and the name(s) and place(s) of birth of the applicant’s parent(s);

(4) Census record showing name, U.S. nationality or a U.S. place of birth, and applicant’s date of birth or age;

(5) Adoption finalization papers showing the applicant’s name and place of birth in one of the 50 states, the District of

Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917,

American Samoa, or the Northern Mariana Islands (on or after November 4, 1986, Northern Marian Islands local time)

(unless the applicant was born to foreign diplomats residing in such a jurisdiction), or, when the adoption is not finalized

and the state or other U.S. jurisdiction listed above will not release a birth certificate prior to final adoption, a statement

from a state or jurisdiction approved adoption agency showing the applicant’s name and place of birth in one of such

jurisdictions, and stating that the source of the information is an original birth certificate;

(6) Any other document that establishes a U.S. place of birth or otherwise indicates U.S. nationality (e.g., a contemporaneous

hospital record of birth in that hospital in one of the 50 states, the District of Columbia, Puerto Rico (on or after January

13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, or the Northern Mariana Islands

2

(on or after November 4, 1986, Northern Mariana Islands local time) (unless the applicant was born to foreign diplomats

residing in such a jurisdiction);


c. Collective Naturalization


If the applicant cannot present one of the documents listed in (a) or (b) above, the following will establish U.S. citizenship for

collectively naturalized individuals:

Puerto Rico:

  • Evidence of birth in Puerto Rico on or after April 11, 1899 and the applicant’s statement that he or she was residing in the U.S., a U.S. possession or Puerto Rico on January 13, 1941; or
  • Evidence that the applicant was a Puerto Rican citizen and the applicant’s statement that he or she was residing in Puerto Rico on March 1, 1917 and that he or she did not take an oath of allegiance to Spain.

U.S. Virgin Islands:

  • Evidence of birth in the U.S. Virgin Islands, and the applicant’s statement of residence in the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927;
  • The applicant’s statement indicating resident in the U.S. Virgin Islands as a Danish citizen on January 17, 1917 and residence in the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927, and that he or she did not make a declaration to maintain Danish citizenship; or
  • Evidence of birth in the U.S. Virgin Islands and the applicant’s statement indicating residence in the U.S., a U.S.possession or territory or the Canal Zone on June 28, 1932.

Northern Mariana Islands (NMI) (formerly part of the Trust Territory of the Pacific Islands (TTPI)):

  • Evidence of birth in the NMI, TTPI citizenship and residence in the NMI, the U.S., or a U.S. territory or possession on November 3, 1986 (NMI local time) and the applicant’s statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time);
  • Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981 (NMI local time), voter registration prior to January 1, 1975 and the applicant’s statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time); or
  • Evidence of continuous domicile in the NMI since before January 1, 1974 and the applicant’s statement that he or she did not owe allegiance to a foreign state on November 4 1986 (NMI local time). Note: If a person entered the NMI as a nonimmigrant and lived in the NMI since January 1, 1974, this does not constitute continuous domicile and the individual is not a U.S. citizen

d. Derivative Citizenship

If the applicant cannot present one of the documents listed in a or b above, the following may be used to make determination of

derivative U.S. citizenship:


Applicant born abroad to two U.S. citizen parents: Evidence of the U.S. citizenship of the parents and the relationship of the

applicant to the parents, and evidence that at least one parent resided in the U.S. or an outlying passion prior to the applicant’s

birth.


Applicant born abroad to a U.S. citizen parent and a U.S. non-citizen national parent: Evidence that one parent is a U.S.

citizen and that the other is a U.S. non-citizen national, evidence of the relationship of the applicant to the U.S. citizen parent,

and evidence that the U.S. citizen parent resided in the U.S., a U.S. possession, American Samoa or Swain’s Island for a period

of at least one year prior to the applicant’s birth.


Applicant born out of wedlock abroad to a U.S. citizen mother: Evidence of the U.S. citizenship of the mother, evidence of

the relationship to the applicant and, for births on or before December 24, 1952, evidence that the mother resided in the U.S.

prior to the applicant’s birth or, for births after December 24, 1952, evidence that the mother had resided, prior to the child’s

birth, in the U.S. or a U.S. possession for a period of one year.


Applicant born in the Canal Zone or the Republic of Panama:

  • A birth certificate showing birth in the Canal Zone on or after February 26, 1904 and before October 1, 1979 and evidence that one parent was a U.S. citizen at the time of the applicant’s birth; or
  • A birth certificate showing birth in the Republic of Panama on or after February 26, 1904 and before October 1, 1979 and evidence that at least one parent was a U.S. citizen and employed by the U.S. government or the Panama Railroad Company or its successor in title. In all other situations in which an applicant claims to have a U.S. citizen parent and an alien parent, or claims to fall within one of the above categories, but is unable to present the listed documentation:
  • If the applicant is in the U.S., the applicant should contact the local U.S. Citizenship and Immigration Service office for determination of U.S. citizenship;
  • If the applicant is outside the U.S., the applicant should contact the State Department for a U.S. citizenship determination.

e. Adoption of Foreign-Born Child by U.S. Citizen

  • If the birth certificate shows a foreign place of birth and the applicant cannot be determined to be a naturalized citizen under any of the above criteria, obtain other evidence of U.S. citizenship;

3

 

Because foreign-born adopted children do not automatically acquire U.S. citizenship by virtue of adoption by U.S. citizens, the applicant should contact the local U.S. Citizenship and Immigration Service office for a determination of U.S. citizenship, if the applicant provides no evidence of U.S. citizenship.

f. U.S. Citizenship By Marriage

A woman acquired U.S. citizenship through marriage to a U.S. citizen before September 22, 1922. Provide evidence of U.S.

citizenship of the husband, and evidence showing the marriage occurred before September 22, 1922.

Note: If the husband was an alien at the time of the marriage, and became naturalized before September 22, 1922, the wife also

acquired naturalized citizenship. If the marriage terminated, the wife maintained her U.S. citizenship if she was residing in the

U.S. at that time and continued to reside in the U.S.


g. A U.S. certificate of birth abroad*

h. A foreign passport with a U.S. Visa*

i. An I-94 form with a photograph

j. A U.S. citizenship and immigration services employment authorization document or refugee travel

document*


LIST B


Qualified Aliens, Nonimmigrant, and aliens paroled into U.S. for less than one year.


a. “Qualified Aliens”

Evidence of “Qualified Alien” status includes the following:

 

Alien Lawfully admitted for Permanent Residence

- *Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”); or

- Unexpired Temporary I-551 stamp in foreign passport or on *I Form I-94.

 

Asylee

- *Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA;

- *Form I-688B (Employment Authorization Card) annotated “274a.12 (a) (5)”;

- *Form I-766 (Employment Authorization Document) annotated “A5”;

- Grant letter from the Asylum Office of the U.S. Citizenship and immigration Service; or

- Order of an immigration judge granting asylum.

 

Refugee

- *Form I-94 annotated with stamp showing admission under § 207 of the INA;

- *Form I-688B (Employment Authorization Card) annotated “274a.12 (a) (3)”; or

- *Form I-766 (Employment Authorization Document) annotated “A5”;

 

Alien Paroled Into the U.S. for at Least One Year

- *Form I-94 with stamp showing admission for at least one year under section 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

- *Form I-688B (Employment Authorization Card) annotated “274a.12 (a) (10)”;

- *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

- *Form I-94 with stamp showing admission under §203 (a) (7) of the INA;

- *Form I-688B (Employment Authorization Card) annotated “274a.12 (a) (3)”; or

- *Form I-766 (Employment Authorization Document) annotated “A3”.

Cuban/Haitian Entrant

- *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 *Form I-94 with the Code CU6 or CU7; or

- *Form I-94 with stamp showing parole as “Cuba/Haitian Entrant” under Section 212 (d) (5) of the INA.

 

Alien who has been Declared a Battered Alien or Alien Subjected to Extreme Cruelty

- U.S. Citizenship and Immigration Service petition and supporting documentation

b. Nonimmigrant

Evidence of “Nonimmigrant” status includes the following:

- *Form I-94 with stamp showing authorized admission as nonimmigrant

c. Alien Paroled into U.S. for less than One year

- *Form I-94 with stamp showing admission for less than one year under section 212 (d) (5) of the INA

d. A foreign passport with a U.S. visa

e. An I-94 form with a photograph.

f. A U.S. citizenship and immigration services employment authorization document or refugee travel

document.

4

 
RocketTheme Joomla Templates