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Ohio Department of Developmental Disabilities

Application for DD Personnel to Attend the DODD Medication Administration (MA) Certification Course

Prior to DODD Medication Administration Certification (Initial Certification class or Renewal): DD Personnel must submit a completed application to the RN Trainer, including all Employer and Personal information and signatures. DD Personnel whose application forms are not completed or without required signatures are not eligible for DODD Medication Administration certification.

DD Personnel: (print)*

PAGE 1: MUST BE FULLY COMPLETED BY EMPLOYER

Date of Application*

Employer

Please Select One Option*

Agency Employer DODD Certified Independent Provider

If you are a DODD Certified Independent Provider, for the purposes of this application, you are the employer

Provider Number*

Work Location

Work Location: At the time of this application, where does this person primarily provide services or supervision?

Please Select One Option*

If other agency location, What is the address?

Work Location Phone:

(If no direct phone or email at location, list DD employer agency phone and email)

Supervisor

At the time of this application, who is the direct supervisor of this DD personnel?

Name & Title of direct supervisor*

Phone for direct supervisor*

Email for direct supervisor*

Please verify all of the following are true as of the date of this application:

Is this person employed by this agency?*

Yes

Start Date

This person is at least 18 years of age*

Yes

The agency has been provided documented proof of this person's high school diploma or equivalency?*

Yes

All background check requirements have been completed according to OAC 5123:2-2-02 including results and registry checks within the specific time frames*

Yes

As the agency employer of the DD personnel whose name appears on this application, I attest that all information provided on this application is accurate and current.

Name & Title of Agency Employee/Designee

Use your mouse or finger to draw your signature below

[clear]

Use your Signature of Agency Employer/Designee

Date*

Ohio Department of Developmental Disabilities

Application for DD Personnel Medication Administration Certification

PAGE 2: MUST BE COMPLETED BY DD PERSONNEL

Prior to attending a DODD MA Certification Course: all information and signatures. Without a completed application DD Personnel will not be eligible for DODD Medication Administration certification to administer medications.

This Application is for:

Select from the following:*

Category 1 - Medication Administration Category 1 Renewal Category 2 - G/J Tube Medications Category 2 Renewal Category 3 - Insulin Category 3 Renewal

Have you ever taken a medication administration certification class before this application?*

Yes No

Personal Information

Last Name*

First Name*

Middle Initial*

Last four digits of social security number*

(not full number)

Date of birth*

Gender*

Male Female

Are you an Independent Provider?*

Yes No

If yes, do you have:

High School Diploma High School Equivalency Document

(Must provide proof to RN Trainer)

Personel Address*

Address Line 1

Address Line 2

City

State

ZIP Code

County*

Home Phone

Work Phone

Cell Phone*

Personel Email:*

Your certificates and renewal notices will be sent to you by e-mail.

You MUST provide an e-mail address where you will reliably receive messages.

At the time of this application, do you work for more than one DD employer?*

Yes No

If Yes please include the names and Provider Number of all DD employers you currently work for:

DD Employer

Provider #

DD Employer

I attest that all information provided on this application is true, current and correct.

Signature of DD Personnel*

[clear]

Use your mouse or finger to draw your signature above

Date*

RN Trainer should keep this application in a retrievable file, which is accessible to authorized personnel and DODD upon request for at least 7 years

RN Trainer Signature (Attesting to Employee Personal Information Only)*

[clear]

(includes validation of HSD/GED for Independent Providers)

Date*

Session # (if Initial Certification - not renewal)

Ohio Department of Developmental Disabilities

Employer

Work Location

Supervisor

At the time of this application, who is the direct supervisor of this DD personnel?

Please verify all of the following are true as of the date of this application:

As the agency employer of the DD personnel whose name appears on this application, I attest that all information provided on this application is accurate and current.

Ohio Department of Developmental Disabilities

Application for DD Personnel Medication Administration Certification

PAGE 2: MUST BE COMPLETED BY DD PERSONNEL

This Application is for:

Personal Information

Your certificates and renewal notices will be sent to you by e-mail.

You MUST provide an e-mail address where you will reliably receive messages.

If Yes please include the names and Provider Number of all DD employers you currently work for:

RN Trainer should keep this application in a retrievable file, which is accessible to authorized personnel and DODD upon request for at least 7 years

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