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Applying for a Certified Nursing Assistant (CNA) license in Florida involves a detailed process, and the CNA License to Florida form is a critical part of that journey. To ensure your application is processed smoothly, it’s essential to follow a comprehensive checklist that outlines the necessary components. The form requires a completed application with your signature, as any omissions can lead to delays in approval. Additionally, you must provide proof of active certification from your home state, ensuring it is in good standing. The application also mandates the completion of a Confidential and Exempt from Public Records Disclosure Form, along with electronically submitted fingerprints via a Livescan provider approved by the Florida Department of Law Enforcement. It's important to note that all documents submitted become a permanent part of your file and cannot be returned. The application must be filled out honestly, as providing false information could result in denial. Furthermore, any changes to your personal circumstances, such as name or address, must be reported in writing to avoid complications. This form not only serves as a gateway to licensure but also emphasizes the importance of transparency regarding your criminal history and disciplinary actions, if any. Understanding these key elements will help you navigate the application process with confidence.
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Application Checklist
Please use the following checklist to help ensure your application is complete.
Completed Application with Signature
An incomplete application will delay final approval of that application. All documents become a permanent part of your file and cannot be returned. Applications are reviewed in date order received.
Every question on the application must be answered. Be sure to answer all questions honestly. The Board of Nursing may deny your application if you provide false information on your application.
Proof of Active Certification
Your
Completed Confidential and Exempt from Public Records Disclosure Form
Form enclosed
Livescan
All applications received must include electronically submitted fingerprints through a Livescan provider. The Department of Health accepts electronic fingerprinting offered by Livescan providers that are approved by the Florida Department of Law Enforcement.
For a list of approved Livescan vendors BOE
Our current ORI number is EDOH4400Z.
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Applications and other additional documents must be mailed to:
Department of Health
Certified Nursing Assistant Registry
4052 Bald Cypress Way Bin#
Tallahassee, FL
Important Information
Application Updates
The Board office must be notified in writing of anything which changes or affects a response given in your application. Failure to do so could result in the delay of application processing or denial of your application. Examples: change of name, address, telephone number, arrests or convictions, licensure status or disciplinary action in another state, or an incorrect answer to a question.
Withdrawal of Application
If you decide to withdraw your application, you must make the request in writing. The request must be received prior to the Board considering licensure.
Criminal History
Any applicant who has ever been found guilty of, or pled guilty or no contest to/nolo contendere, any charge other than a minor traffic offense must list each offense on the application. Failure to disclose criminal history may result in denial of your application. Each application is reviewed on its own merits. Staff cannot make predeterminations in advance as laws and rules do change over time.
Violent crimes and repeat offenders are required to be presented to the Board of Nursing for review.
Applicants with criminal convictions may be required to submit the following documents:
Final Dispositions/Sanctions
clerk of the court in the arresting jurisdiction. If the records are not available, you must have a letter on court letterhead sent from the Clerk of the Court attesting to their unavailability.
Completion of Probation/Parole
Letters of Recommendation
Disciplinary History
Any applicant who has ever been denied, had disciplinary action, or surrendered a license to practice in any healthcare profession, in any state, jurisdiction, or country must provide a
Healthcare Fraud
IMPORTANT NOTICE: Applicants for licensure, certification or registration and candidates for examination may be excluded from licensure; certification or registration if their felony conviction falls into certain timeframes as established in Section 456.0635(2), Florida Statutes. For more information,
please visit our website at:
Florida Board of Nursing
PO Box 6330
Tallahassee, FL 32314
Phone: (850)
Fax: (850)
Certified Nursing Assistant Licensure by Endorsement Application
Website: www.floridasnursing.gov
Email: [email protected]
Please complete this application in its
entirety prior to printing.
1.PERSONAL INFORMATION
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Physical Location: (Required if mailing address is a P.O. Box- This address will be posted on the Department of Health's website.)
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EQUAL OPPORTUNITY DATA:
We are required to ask that you furnish the following information as part of your voluntary compliance with Section 2, Uniform Guidelines on Employee Selection Procedure (1978) 43 CFR 38295 and 38296 (August 25, 1978). This information is gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure.
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Black or African American |
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Hispanic |
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American Indian or Alaska Native |
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Native Hawaiian or Other Pacific Islander |
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Two or More Races |
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Email Notification: If you want to be notified of the status of your application by email please check the "Yes" box and write your email address on the line provided below. If you choose this form of notification you will receive information
regarding your application file through email. You will be responsible for checking your email regularly and updating your email address with the Board office at: [email protected]
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Under Florida law, email addresses are public records. If you do not want your
2.APPLICANT BACKGROUND Attach additional sheets, if necessary
A.List any other name(s) by which you have been known in the past.
B.What name(s) did you use when you received your education?
C.What name did you use when you were first licensed?
D.Have you ever applied for licensure by examination in Florida, as a CNA? Date
Yes No
E.Have you ever applied for licensure by endorsement in Florida, as a CNA? Date
Yes No
F.Have you ever been licensed in Florida as a CNA? Date
Yes No
G.* Have you ever been denied or is there now any proceeding to deny your application for any health care license to practice in Florida or any other state, jurisdiction or country?
Yes No
*If you answer “Yes” to question G in this section, you must submit a self explanation as to why you are answering “Yes” to this question.
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H. List all CNA licenses ( active, inactive or lapsed)
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Status of License and Expiry Date |
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The Florida Board of Nursing requires verification of licensure from from a state where you have a current active license.
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CRIMINAL HISTORY |
Answers to commonly asked questions can be found on our website at: |
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Have you EVER been convicted of, or entered a plea of guilty, nolo contendere, or no |
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contest to, a crime in any jurisdiction other than a minor traffic offense? You must |
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include all misdemeanors and felonies, even if adjudication was withheld. |
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Reckless driving, driving while license suspended or revoked (DWLSR), driving |
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under the influence (DUI) or driving while impaired (DWI) are not minor traffic offenses |
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for purposes of this question. |
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No Have you EVER had any records sealed pursuant to section 943.059, F.S., or other states |
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applicable statute? |
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Have you EVER been adjudicated delinquent? |
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Failure to disclose information in this section may result in a denial of your application.
If you answered “Yes” to any of the questions above you are required to send the following items:
Self Explanation describing in detail the circumstances surrounding each offense; including dates, city and state, charges and final results.
Final Dispositions and Arrest Records for all offenses. The Clerk of the Court in the arresting jurisdiction will provide you with these documents. Unavailability of these documents must come in the form of a letter from the Clerk of the Court.
Completion of Sentence Documents. You may obtain documents from the Department
of Corrections. The report must include the start date, end date, and state that the conditions have been met.
Three (3) current (written within the last year) Letters of Recommendation.
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4. |
Electronic Fingerprinting: |
(Required for ALL applicants) |
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All applicants, including
Typically background results submitted by Livescan are received by the Board within
Livescan screenings done by a Florida Police or Sheriff's Department require that you login to the FDLE Civil Applicant Payment System (CAPS) at https://caps.fdle.state.fl.us and pay a fee before results will be released to our office.
Applicants who reside in an area where no Livescan service providers are available or because of state laws prohibiting transmission of fingerprints electronically across state lines should contact a Florida Livescan service provider who has the capability to convert a traditional card (hard card) into an electronic fingerprint card.
Because the Florida Department of Health retains fingerprints on any applicant who is required to undergo a criminal history screening as of January 1, 2013, those prints are retained in the Care Provider Clearinghouse. This Clearinghouse allows for the sharing of criminal history information among specified agencies.
One of the requirements for your Livescan to be retained in the Clearinghouse is a photograph taken by the Livescan service provider at time of fingerprinting. If your Livescan is completed without a photograph, you may have to undergo additional fingerprinting in the future.
Applicants needing hard fingerprint cards can request them via email at: [email protected]
Please include your current mailing address in your request for fingerprint cards.
The Board cannot accept hard fingerprint cards or results.
For Frequently Asked Questions about Livescan and for a list of providers who offer hard card conversion see our website at:
LIVESCAN PRIVACY STATEMENT
I have been provided and read the statement from the Florida Department of Law Enforcement regarding the sharing, retention, privacy and right to challenge incorrect criminal history records and the “Privacy Statement” document from the Federal Bureau of Investigation. (Found in the forms following this application). The Board will not receive your Livescan results if you do not affirm the above statement by checking this box.
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5.
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DISCIPLINARY HISTORY
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Have you ever had disciplinary action taken against your license to practice any |
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health care related profession by the licensing authority in Florida or in any other state, |
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jurisdiction or country? |
Yes No Have you ever surrendered a license to practice any health care related profession in Florida or in any other state, jurisdiction or country while any such disciplinary charges were pending against you?
Yes No Do you have disciplinary action pending against any license?
Failure to disclose information in this section may result in a denial of your application.
If you answered “Yes” to any of the questions in this section, you are required to send the following items:
Self Explanation, describing in detail the circumstances surrounding the disciplinary action.
A copy of the Administrative Complaint and Final Order.
Three (3) current (written within the last year) Letters of Recommendation.
6. CRIMINAL AND MEDICAID/MEDICARE FRAUD QUESTIONS
IMPORTANT NOTICE: Applicants for licensure, certification or registration and candidates for examination may be excluded from licensure, certification or registration if their felony conviction falls into certain timeframes as established in Section 456.0635(2), Florida Statutes. If you answer “Yes” to any of the following questions, please provide a written explanation for each question including the county and state of each termination or conviction, date of each termination or conviction, and copies of supporting documentation to the address below. Supporting documentation includes court dispositions or agency orders where applicable.
1. Yes No Have you been convicted of, or entered a plea of guilty or nolo contendere, regardless of adjudication, to a felony under Chapter 409, F.S. (relating to social and economic assistance), Chapter 817, F.S. (relating to fraudulent practices), Chapter 893, F.S. (relating to drug abuse prevention and control) or a similar felony offense(s) in another state or jurisdiction?
If you responded “No”to the question above, skip to question 2.
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No If “Yes” to 1, were you arrested or charged for the felony or felonies after July 1, 2009? |
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No If “Yes” to 1, for the felonies of the first or second degree, has it been more than 15 |
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years from the date of the plea, sentence and completion of any subsequent probation? |
c. Yes No If “Yes” to 1, for the felonies of the third degree, has it been more than 10 years from the date of the plea, sentence and completion of any subsequent probation? (This question does not apply to felonies of the third degree under Section 893.13(6)(a), Florida Statutes).
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NAME ______________________________________________
d. Yes No If “Yes” to 1, for the felonies of the third degree under Section 893.13(6)(a), Florida Statutes, has it been more than 5 years from the date of the plea, sentence and completion of any subsequent probation?
2.
e. Yes No
Yes No
If “Yes” to 1, have you successfully completed a drug court program that resulted in the plea for the felony offense being withdrawn or the charges dismissed? (If “Yes”, please provide supporting documentation).
Have you been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, to a felony under 21 U.S.C. ss.
Medicare and Medicaid issues)?
3.
4.
5.
If you responded “No” to the question above, skip to question 3.
a. |
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No If “Yes” to 2, were you arrested or charged for the felony or felonies after July 1, 2009? |
b. Yes No If “Yes” to 2, has it been more than 15 years before the date of application since the sentence and any subsequent period of probation for such conviction or plea ended?
Yes No Have you ever been terminated for cause from the Florida Medicaid Program pursuant to Section 409.913, Florida Statutes?
If you responded “No” to the question above, skip to question 4.
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No If you have been terminated but reinstated, have you been in good standing with the |
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Florida Medicaid Program for the most recent five years? |
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Have you ever been terminated for cause, pursuant to the appeals procedures |
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established by the state, from any other state Medicaid program? |
If you responded “No” to the question above, skip to question 5.
a. Yes No Have you been in good standing with a state Medicaid program for the most recent five years?
b. Yes No Did the termination occur at least 20 years before to the date of this application?
Yes No Are you currently listed on the United States Department of Health and Human Services' Office of Inspector General's List of Excluded Individuals and Entities?
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7.
Confidential and Exempt from Public Records Disclosure
Pursuant to Sec. 466 [42 U.S.C. 666](a), the department is required and authorized to collect Social Security Numbers relating to applications for professional licensure. Additionally, section 456.013(1)(a), Florida Statutes, authorizes the collection of Social Security Numbers as part of the general licensing provisions. This information is exempt from public records disclosure.
Last Name:
First Name:
Middle Name:
Social Security Number:
(Input with dashes)
Social Security Information - * Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Section 456.013(1), 409.2577 and 409.2598, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title
Board of Nursing
4052 Bald Cypress Way, Bin # C02
Tallahassee, Florida
Phone: (850)
Website: www.floridasnursing.gov
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8. HEALTH HISTORY (Supporting documentation should be sent directly to the board office.)
A. Yes No
B. Yes No
Do you have any condition that currently impairs your ability to practice your profession with reasonable skill and safety?
Are you using medications, other drugs, narcotics, or intoxicating chemicals that impair your ability to practice your profession with reasonable skill and safety?
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If you answered “Yes” to any of the questions in this section, you are required to send the following items:
Please provide a letter from a licensed health practitioner, who is qualified by skill and training to address your condition, which explains the impact your condition may have on your ability to practice your profession with reasonable skill and safety, and stating either that you are safe to practice your profession without restriction or indicating what restrictions are necessary. If necessary, you may
attach additional sheets.
Documentation must be current within the last year.
If you fail to disclose the information requested in this section, your application may be denied.
Self Explanation, explaining the medical condition(s) or occurrence(s) and current status.
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Form Specifications
| Fact Name | Details |
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| Application Requirement | All applications must be completed and signed to avoid delays in processing. |
| Proof of Certification | Applicants must provide proof of active certification that is clear and in good standing. |
| Fingerprint Requirement | Electronic fingerprints must be submitted via an approved Livescan provider. |
| Application Updates | Notify the Board of any changes affecting your application in writing to avoid delays. |
| Withdrawal Process | Requests to withdraw an application must be made in writing before the Board's review. |
| Criminal History Disclosure | Applicants must disclose all criminal history, including misdemeanors, to avoid application denial. |
| Disciplinary History | Any past disciplinary actions against healthcare licenses must be reported and explained. |
| Healthcare Fraud Notice | Felony convictions may lead to exclusion from licensure as per Section 456.0635(2), Florida Statutes. |
| Documentation Responsibility | Applicants must ensure that all required documentation is submitted to the Florida Board. |
| Contact Information | For inquiries, contact the Florida Board of Nursing at (850) 245-4125 or via email at [email protected]. |
Cna License To Florida: Usage Guidelines
Filling out the CNA License to Florida form requires careful attention to detail. Each section must be completed accurately to avoid delays in processing. Once the form is filled out, you will need to submit it along with additional documentation as specified in the instructions.
- Personal Information: Fill in your name, date of birth, mailing address, and contact information. Ensure your home and work phone numbers are entered correctly.
- Equal Opportunity Data: Provide your sex and race for statistical purposes. This information is voluntary and does not affect your application.
- Email Notification: Indicate whether you want to receive updates about your application via email. If yes, enter your email address.
- Applicant Background: List any previous names, names used during your education, and any names associated with past licenses. Answer questions about prior applications for licensure in Florida.
- Criminal History: Answer questions regarding any past convictions or legal issues. If you answer "Yes" to any question, prepare to provide detailed explanations and supporting documents.
- Proof of Active Certification: Ensure your out-of-state certificate is clear and in good standing. This may require verification from the issuing state.
- Livescan Fingerprinting: Arrange for electronic fingerprinting through an approved Livescan provider. This is mandatory for all applicants.
- Submission: Mail the completed form along with any required documents to the specified address: Department of Health, Certified Nursing Assistant Registry, 4052 Bald Cypress Way Bin# C-02, Tallahassee, FL 32399-3252.
Your Questions, Answered
What is the purpose of the CNA License to Florida form?
The CNA License to Florida form is used by individuals seeking to obtain a Certified Nursing Assistant license in Florida. This application ensures that candidates meet the necessary qualifications and standards set by the Florida Board of Nursing. Completing this form is the first step in the licensing process, which includes submitting personal information, proof of certification, and background checks.
What documents are required to complete the application?
To complete the application, you must provide several documents. These include a completed application with your signature, proof of active certification from your out-of-state license, and a completed Confidential and Exempt from Public Records Disclosure Form. Additionally, you must submit electronically processed fingerprints through a Livescan provider approved by the Florida Department of Law Enforcement. All these documents must be submitted to the Department of Health for processing.
How do I submit my fingerprints for the application?
You can submit your fingerprints electronically through a Livescan provider. It is essential to choose a provider that is approved by the Florida Department of Law Enforcement. A list of these approved vendors can be found on the Florida Department of Health's website. Make sure to complete this step, as it is a critical part of your application process.
What should I do if I need to withdraw my application?
If you decide to withdraw your application, you must submit a written request to the Board of Nursing. This request should be made before the Board considers your application for licensure. Remember that once the Board begins reviewing your application, it may not be possible to withdraw without going through the formal process.
What happens if I have a criminal history?
If you have ever been convicted of a crime, except for minor traffic offenses, you must disclose this information on your application. The application requires you to list each offense and provide a self-explanation of the circumstances surrounding it. Depending on the nature of your offenses, you may also need to submit additional documents, such as final disposition records and letters of recommendation.
How can I ensure my application is processed without delays?
To avoid delays in processing your application, make sure to complete every section of the form accurately and honestly. Incomplete applications will not be processed until all required information is provided. Notify the Board in writing of any changes that may affect your application, such as changes to your name, address, or criminal history.
What if I have had disciplinary action against my license in another state?
If you have experienced any disciplinary action against your healthcare license in any state or jurisdiction, you must disclose this on your application. You will need to provide a self-explanation of the circumstances and ensure that the relevant state board submits documentation regarding the disciplinary action directly to the Florida Board.
Can I receive updates on my application status via email?
Yes, you can opt to receive updates about your application status through email. If you choose this option, you must provide your email address on the application form. However, be aware that under Florida law, email addresses are considered public records. If you prefer to keep your email private, consider contacting the Board by phone or in writing instead.
Where do I send my completed application and documents?
Your completed application, along with all required documents, should be mailed to the following address: Department of Health, Certified Nursing Assistant Registry, 4052 Bald Cypress Way, Bin# C-02, Tallahassee, FL 32399-3252. Make sure to check that all documents are included to prevent delays in processing.
Common mistakes
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Incomplete Application: Failing to complete every section of the application can lead to delays. All questions must be answered fully and honestly.
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Missing Signature: Not signing the application is a common oversight. A signature is essential for the application to be considered valid.
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Incorrect Criminal History Disclosure: Omitting or misrepresenting any past criminal history can result in denial. It is crucial to disclose all relevant offenses, regardless of their severity.
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Failure to Submit Required Documents: Not including necessary documents, such as proof of active certification or fingerprinting results, can halt the application process.
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Ignoring Application Updates: Not notifying the Board of any changes in personal information, such as name or address, can lead to complications in processing the application.
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Inadequate Self-Explanations: When answering questions about previous denials or criminal history, applicants must provide detailed explanations. Vague responses may lead to further scrutiny.
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Providing False Information: Intentionally giving false information can lead to immediate denial of the application. Honesty is essential throughout the process.
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Neglecting to Check Email: If opting for email notifications, applicants should regularly check their email for updates. Missing important communications can delay the application process.
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Not Following Submission Guidelines: Applications must be mailed to the correct address. Misaddressing or failing to follow submission instructions can cause significant delays.
Documents used along the form
When applying for a Certified Nursing Assistant (CNA) license in Florida, several additional forms and documents may be required. These documents support your application and ensure that it is processed smoothly. Below is a list of some commonly used forms along with brief descriptions of each.
- Proof of Active Certification: This document verifies that your out-of-state CNA certification is current and in good standing. It is essential for demonstrating your qualifications.
- Confidential and Exempt from Public Records Disclosure Form: This form is included in the application packet and allows you to request that certain personal information remains confidential and not disclosed to the public.
- Livescan Fingerprint Submission: A Livescan fingerprint submission is mandatory for all applicants. This process involves electronically submitting your fingerprints through an approved provider to conduct a background check.
- Self-Explanation for Criminal History: If you have any criminal history, you will need to provide a written explanation detailing the circumstances surrounding each offense, including dates and outcomes.
These documents play a crucial role in the application process for a CNA license in Florida. Ensuring that you have all the necessary paperwork can help avoid delays and streamline your journey toward licensure.
Similar forms
The CNA License to Florida form shares similarities with several other important documents related to professional licensing and certification. Below is a list of eight documents that exhibit comparable features:
- Application for Nursing License - Like the CNA License form, this application requires personal information, proof of education, and background checks. Both documents emphasize the need for complete honesty in disclosures.
- Application for Medical Assistant Certification - Similar to the CNA form, this document includes a checklist to ensure all required information is submitted. Both applications necessitate proof of active certification and background verification.
- Pharmacy Technician License Application - This application also demands detailed personal information, proof of training, and a criminal background check. Both forms require applicants to disclose any past legal issues.
- Physical Therapy Assistant License Application - This document parallels the CNA form by requiring proof of education, completion of an application checklist, and submission of fingerprints for background checks.
- Occupational Therapy Assistant License Application - Similar to the CNA application, this form requires applicants to provide personal history, educational background, and any disciplinary actions taken against them in the past.
- Emergency Medical Technician (EMT) Certification Application - Like the CNA form, this application includes a comprehensive checklist and mandates background checks, ensuring that all applicants meet the necessary qualifications.
- Licensed Practical Nurse (LPN) Application - This document shares the same structure as the CNA application, requiring proof of education, a completed checklist, and background information, including any criminal history.
- Registered Nurse (RN) Application for Licensure - This application is similar in that it requires detailed personal and educational information, along with a thorough background check, to ensure the applicant's qualifications and integrity.
Dos and Don'ts
When filling out the CNA License to Florida form, it's crucial to follow certain guidelines to ensure your application is processed smoothly. Here are eight important dos and don'ts to keep in mind:
- Do answer every question on the application honestly.
- Do provide proof of active certification from your out-of-state certificate.
- Do submit your fingerprints through an approved Livescan provider.
- Do notify the Board of Nursing in writing about any changes to your application information.
- Don't leave any questions unanswered; an incomplete application will delay processing.
- Don't provide false information; this could lead to denial of your application.
- Don't forget to withdraw your application in writing if you choose to do so.
- Don't neglect to disclose any criminal history; failure to do so may result in denial.
Following these guidelines can help you avoid unnecessary delays and complications. Take the time to review your application before submitting it, ensuring all requirements are met.
Misconceptions
Here are nine common misconceptions about the CNA License to Florida form, along with explanations to clarify each point.
- All applications are processed in the order they are received. Many believe that applications are prioritized based on urgency. In reality, they are reviewed strictly in the order they arrive.
- You can submit an incomplete application. Some think that they can send in an application even if it's missing information. This is incorrect; an incomplete application will delay processing.
- Your documents will be returned after processing. Many applicants assume that their submitted documents will be returned. However, all documents become a permanent part of your file and cannot be returned.
- Only major crimes need to be reported. It's a common belief that only serious offenses matter. In fact, any criminal history, even minor offenses, must be disclosed on the application.
- Fingerprinting is optional. Some applicants think they can skip the fingerprinting process. This is a misconception; all applications require electronically submitted fingerprints through an approved Livescan provider.
- Once submitted, you cannot make changes to your application. Many believe that their application is final once sent. However, you must notify the Board in writing of any changes affecting your application.
- Letters of recommendation are not necessary. Some applicants think they can get by without recommendations. If you have a criminal history, 3-5 letters of recommendation are required.
- Criminal history does not affect your application. There is a misconception that past offenses will not impact your chances. However, failing to disclose your criminal history can lead to denial.
- Email notifications are mandatory. Some applicants think they must provide an email address. In fact, it is optional, and if you prefer not to disclose it, you can choose other forms of communication.
Key takeaways
Key Takeaways for Filling Out the CNA License to Florida Form:
- Ensure that the application is completed in full and signed. An incomplete application can lead to delays in processing.
- Provide proof of active certification from your out-of-state certificate, which must be clear and in good standing.
- Include electronically submitted fingerprints through an approved Livescan provider. This step is mandatory for all applications.
- Notify the Board in writing of any changes that may affect your application, such as name or address changes, as this can impact processing time.
- Be transparent about your criminal history. Any undisclosed offenses may result in denial of your application.