TX HHS Form 5518-NFA. Provisional Licensure Questionnaire

The TX HHS Form 5518-NFA, Provisional Licensure Questionnaire, is a crucial document for individuals seeking provisional licensure as a Nursing Facility Administrator (NFA) in the state of Texas. This form helps applicants provide essential information to facilitate the verification process and obtain provisional licensure.

The questionnaire consists of two main sections: Applicant Information and Employment Information. The applicant must provide their personal details, including name, social security number, date of birth, email address, and phone number. Additionally, they must disclose their employment history, specifically highlighting at least one year of experience as the administrator of record in their state. The form also requires applicants to identify a Provisional License Sponsor, who will support them during the provisional licensure period.

This form should be used by individuals seeking provisional licensure as an NFA in Texas. It is essential for applicants to carefully complete all sections and provide accurate information to ensure a smooth verification process. The form explicitly mentions that if the state cannot verify education, internship, exam scores, and courses, it is the applicant's responsibility to submit proof along with this questionnaire.