New Jersey Nurse Aide Recertification Form

Section 1 – Certificate Information

Name: GALLY MICHEL SSN: XXX-XX-4531

Certification#: NA8245911 Issue Date: Jun 23, 2004 Expiration Date: Aug 9, 2021

Employer Name: NONE Employer Code:

Hire Date: Jan 11, 2017

Certificate Holder Address: Please check here if your address has changed and enter the changes in Section 6 below.
GALLY MICHEL
24 Raven Ave
PISCATAWAY, NJ 08854

PLEASE NOTE THAT THIS RECERTIFICATION FORM MUST BE SUBMITTED IN ACCORDANCE WITH THE PROCEDURE SET FORTH IN
SECTION 4 OF THIS FORM PRIOR TO THE EXPIRATION DATE SHOWN IN SECTION 1 . FAILURE TO RENEW YOUR CERTIFICATION BEFORE
THE EXPIRATION DATE WILL RESULT IN THE IMMEDIATE EXPIRATION OF YOUR CERTIFICATION, AND YOU CANNOT WORK AS A NURSE
AIDE IF YOUR CERTIFICATION HAS EXPIRED.
IF YOU DO NOT SUBMIT THIS RECERTIFICATION FORM PRIOR TO THE EXPIRATION DATE, YOU CANNOT RENEW YOUR CERTIFICATION.
YOU WILL THEN HAVE TWO OPTIONS:
1. IF YOUR INITIAL CERTIFICATION WAS ISSUED WITHIN THE LAST FIVE YEARS, YOU CAN REQUEST A WAIVER; OR
2. IF YOUR INITIAL CERTIFICATION WAS ISSUED MORE THAN FIVE YEARS AGO, YOU MUST RE-TRAIN AND SIT FOR THE EXAMS.
QUESTIONS ABOUT THESE OPTIONS SHOULD BE REFERRED TO THE CERTIFICATION PROGRAM AT (609) 292-5441.
Section 2 – Declaration and Signature of Administrator/Designee
(This section must be completed by a LICENSED HEALTH CARE FACILITY EMPLOYER)
Facility Name: Facility Address:

Employer Code: Date of Hire: Date of Termination:

The above-named has been employed either directly in or under supervision by (name of health care facility)

providing nursing or nursing related services for pay for at least 7 hours within the last 24 months prior to the expiration
date on the certification. I certify that the information put forth on the recertification form is true and correct to the best of my knowledge.

Signature: Print Name: Date:

Section 3 – Criminal Background Investigation (CBI) Update Process

The Laws of the State of New Jersey, specifically N.J.S.A. 26:2h-83, et seq., require that all individuals applying for renewal of their Nurse Aide
certification undergo an updated Criminal Background Investigation (CBI). You have previously received a notice from New Jersey Department of
Health Department explaining the process for obtaining this updated CBI. Please note that you MUST complete the CBI renewal process before the
expiration date shown in Section 1 of this form. If you fail to complete the CBI renewal process before the certification expriation date, you cannot work
as a Nurse Aide.
A note about confidentiality: Any information the NJDOH obtains in the course of your CBI process is kept confidential.
The NJDOH does not share or disclose this information with any other party, unless required by court order. Moreover, the NJDOH will not release the
details of your criminal history to your employer. However, in the event that you are disqualified from certification, the NJDOH is required by law to
notify your employer. Please note that PSI Services does not have access to any CBI information. Therefore, if you have questions about the CBI
process, please call the NJDOH CBI unit at (609) 292-4303.

Section 4 – How to Obtain Your New Certificate

Take this recertification form (signed by your health care facility employer in Section 2) to a PSI Services Assessment Center listed below to obtain
your new certificate and wallet identification card. At the PSI Services Assessment Center, you will be required to also show 2 forms of signature
identification, one of which must also show your photo. You will also be required to make a payment of $30 via Visa or MasterCard, cashier’s check, or
money order (cash or personal checks are NOT accepted). If you have a pre-paid recertification voucher issued to you by your employer or other
institution, please enter your code in the box below your signature.For further questions about recertification, please contact the PSI Assessment
Center at 1-877-774-4243, Select OPTION #1, Registry Questions.
Section 5 – Declaration and Signature of Certificate Holder

I agree that the NJDOH may investigate the accuracy of the information contained on this form. I hereby given permission for NJDOH to obtain and/or
update criminal history information from the New Jersey State Police and the Federal Bureau of Investigation. I have been employed a licensed health
care facility or under the supervision of a licensed health care facility providing nursing or nursing-related services for at least 7 hours for pay within the
24 months prior to the expiration date on my certificate. I understand that if I have given false information on this document, I may lose my certification.
I have read and understand the information and authorize the placement of my name on the Nurse Aide Registry.

Signature: Print Name: Date:

Voucher Code:

(for PSI use only)

Section 6 – Certificate Holder Change of Address

Address1:
Address2:
City: State: Zip Code:
Section 7 – PSI Services Assessment Center Locations and Recertification Times

NOTE: Person(s) accompanying a recertification candidate may not wait in the test center, inside the building, or on building property. This applies to
guests of any nature, including drivers, children, friends, family or colleagues.

Address Recertification hours Driving Directions

Brick, NJ 08723 Monday From the Garden State Parkway South:

10:00am-4:00pm Take Exit 91/CR-549 towards Lakewood/Brick Township.
Stay on CR-549/Lanes Mill Road until it turns into
Wednesday CR-549/Chambers Bridge Road.
10:00am-4:00pm 260 Chambers Bridge Road is on the right immediately after the
260 Chambers Bridge Rd. Sprucewood Drive light.
Unit # 1A From the Garden State Parkway North:
Take Exit 90 and merge onto Chambers Bridge Road.
Then follow the directions above.

Cherry Hill, NJ 08034 Monday From the I-295 South:

10:00am-7:00pm Take Exit 34B toward Cherry Hill/Camden.
Merge onto Marlton Pike/NJ-70W.
950 Kings Highway North Wednesday Make a slight right turn onto King Highway North/NJ-41.
Suite 301 10:00am-4:00pm Continue to the PSI Assessment Center located behind
buildings #900 and #1030.

Hamilton Township, NJ 08619 Monday From the I-295 North:

10:00am-4:00pm Take Exit 65A/Sloan Ave East/CR-649. Merge onto Sloan Ave.
Continue on Sloan Ave, turning left onto Quakerbridge
3525 Quakerbridge Rd Wednesday Road/CR-533.Continue to 3525 Quakerbridge Road on the
Suite 1000 10:00am-4:00pm right.

Linwood, NJ 08221 Monday From the Garden State Parkway South:

10:00am-4:00pm Take Exit #36/Northfield/Margate onto Tilton Road (CR-563).
Bear right on New Road (US-9).
222 New Road, Suite 301 Continue to 222 New Road on the left.

New Brunswick - Georges Road Wednesday From NJ - 18 N :

10:00am-4:00pm Merge on to US - 1 S/US Highway 1 towards Trenton.
825 Georges Road, Suite 2A Take the NJ - 171 N Ramp towards US - 130 S/Camden/New
North Brunswick, NJ 08902 Brunswick. Keep right at the fork in the ramp. Turn right onto
Georges rd.

New Providence, NJ 07974 Monday From I-78 West:

10:00am-4:00pm Take Exit 43 toward New Providence/Berkeley Heights.
Turn slight turn onto CR-655/Diamond Hill Rd
Turn slight right onto CR-622/Mountain Ave
Murray Hill Office Center Turn left onto CR-647/South St.
571 Central Avenue, Suite 117 Turn left onto Central Ave.
Continue to 571 Central Avenue on the right.

North Brunswick, NJ 08902 Monday From I-95 South/New Jersey Turnpike South:
10:00am-4:00pm Take Exit 9 toward US-1/New BrunswicK/Princeton/
Trenton/Tower Center Blvd.Stay straight to go onto NJ-18N.
Merge onto US-1 S towards Trenton.
The Shoppes at North Brunswick Take the right-171 N ramp towards New Brunswick.
980 Shoppes Blvd, 2nd floor Turn left onto US-130/St. Georges Road.
Turn right onto Shoppes Blvd. 980 is on the right.

Parsippany, NJ 07054 Monday From the I-280 West:

10:00am-4:00pm Take Exit #1/New Road towards US-46.
Make a slight right onto New Road.
239 New Road, Bldg. A Thursday Continue to 239 New Road on the right.
Suite 203, Second Floor 4:00pm-7:00pm
Secaucus, NJ 07094 Monday From I-95 N:
10:00am-4:00pm Take Rt - 3 Exit, Exit 16W towards Secaucus/Rt, 120/Lincoln
110-B Meadowlands Parkway Tunnel, turn right onto S Service Road, merge onto Rt. 3 E.
Suite 204 Take the Meadowlands Parkway exit.