N.C. Department of Health and Human Services
Division of Health Service Regulation
Health Care Personnel Registry Section

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Forms

The following forms are available from the Health Care Personnel Registry Section. If you do not see the form you need, please check our Publications page, or contact us.

For Nurse Aides and Medication Aides:

• RNs and LPNs listing as Nurse Aides: Application to be listed on North Carolina Nurse Aide I Registry (PDF, 52 KB)
• Change of information: Name/Address Change Reporting Form (PDF, 44 KB)
• Duplicate renewal form: Request for Replacement (Duplicate) Renewal Form (PDF, 43 KB)

For Providers Reporting Allegations to the HCPR Section:

Forms are optional. Reporting requirements are found in the 2008 HCPR Section Handbook (PDF, 587 KB).

• Allegation report: 24-Hour Initial Report (first report of allegation) (PDF, 93 KB)
• Investigation report: 5-Working Day Report (follow up investigation report) (PDF, 181 KB)

For Existing, State-Approved Nurse Aide I Training Programs Only:

• Clinical site changes: Clinical Site Approval Form (PDF, 20 KB)
• Faculty additions: Faculty Approval Request Form (PDF, 52 KB)
• Faculty deletions: Faculty Removal Request Form (PDF, 32 KB)

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• Updated: November 4, 2008
• N.C. Division of Health Service Regulation