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​Instructions for Completing the Pennsylvania Nurse Aide Training Report

Revised: July 2022

Print or type the requested information on the Pennsylvania Nurse Aide Training Report. If more than ten (10) students are accepted for a nurse aide class, an additional Pennsylvania Nurse Aide Training Report must be thoroughly completed, including signatures.

The designated program representative (administrator or coordinator) is responsible for ensuring that all spaces and columns of program or student information are complete and accurate. Only the information requested should be entered on this form.

The Pennsylvania Nurse Aide Training Report is an ad infinitum document.  Most sections can be completed on or before the first day of class.

Header Section

  • Enter the approved Nurse Aide Training and Competency Evaluation Program (NATCEP) name and complete mailing address.
  • Enter the name and mailing address of the clinical site where students completed their clinical experience. If the student was assigned to residents at two different clinical sites, enter the name and address of the second clinical site on the back of the Pennsylvania Nurse Aide Training Report. If the clinical site is the same as the program, leave the space blank.
  • Document the total program hours and distribution of theory, lab, and clinical hours. 
  • Record the 7-digit training program code number. 
  • Record the class start and completion dates. 
  • Record the number of applicants accepted into class. 

Student Information Section

  • Student Name - Alphabetize by students' last name.
  • Address - Complete mailing address, city, state, zip code.
  • Birth Date - MM/DD/YYYY.
  • PA Residency - Mark either the Yes or No box as verification of PA residency for the last two consecutive years prior to enrolling in NATCEP. 
  • PA Criminal History Report Information Date Reviewed by NATCEP - Record the date the NATCEP representative signed and dated the student's CHRI as attestation of compliance with the Prohibitive Offenses contained in Act 14 (P.L. 169).
  • PA CHRI Date Disseminated by the Pennsylvania State Police - record the date when the CHRI was disseminated by the Pennsylvania State Police (NOT the date the CHRI was requested).
  • Date the FBI report was reviewed by the NATCEP - enter the date the NATCEP reviewed the student's FBI report. If an FBI report is not required for enrollment in a nurse aide class based on residency in PA for the last two consecutive years, leave the space blank. Do not write "N/A." 
  • Date of Hire - Record the date the student is placed on the payroll as a nurse aide.     Be advised that some health care facilities hire employees and place them on the payroll as a nurse aide prior to enrolling them in class. 
  • Date Student Completed Training – Record the date the student completed all program requirements. If the student was required to make up missed time, then the date of training program completion could be different from other students. If a student withdraws from class or is dismissed, record the actual date of withdrawal and a brief explanation. The explanation may extend into adjacent columns. Anecdotal notes should be retained in the student's record.  Examples: 9/13/21 No Call/ No Show (NC/NS) dismissed per student policy or 9/13/21 Dismissed due to unsuccessful academic achievement or 9/13/21 Dismissed due to unsuccessful clinical achievement. 
  • Date of CEP (Competency Evaluation Program) Exam - Record the date the student took the Pennsylvania Nurse Aide Competency Examination. Place the first exam date on the first line. This information can be obtained by checking the PA nurse aide registry. If the student needs a second or third attempt to pass the examination, enter the corresponding date(s). 
  • Written P/F - Enter a mark in the Written column to indicate a P (Pass) or F (Fail) for the result of the written examination. If the exam is taken orally, indicate an "O" or by interpreter, an "I". 
  • Skills P/F - Enter a mark in the Skills column to indicate a P (Pass) or F (Fail) for the result of the skills exam.

Footer Section

  • Provide an instructor's signature, license information and date. If more than one instructor taught the class, program determines who must sign this document. 
  • If an LPN taught any/all the NATCEP, provide the signature of the RN supervisor, license number and date. If more than one RN supervisor, program determine who must sign. 
  • Provide the school/facility administrator's signature, date, phone number, and professional license information, if applicable. 
  • Provide the signature of the NATCEP representative designated to review Pennsylvania CHRI and FBI letters, date, and phone number.