This form may be completed online and submitted to the address below 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the facility name in the designated field. This identifies where the individual worked.
3. Next, fill in the city, state, and ZIP code of the facility to provide complete location details.
4. Input the individual's Social Security Number or Registry Number in the appropriate section for identification purposes.
5. Enter the individual's full name, including last, first, and middle names as required.
6. Record the date of hire and date terminated in their respective fields to document employment duration.
7. Once all fields are completed, review your entries for accuracy before submitting.
8. Submit the form electronically via our platform or print it out and send it to the Nebraska Nurse Aide Registry at the provided address.

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