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.

Date of Application*


Please Select One Option*

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

Work Location

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

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


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:

Is this person employed by this agency?*
Start Date
This person is at least 18 years of age*
The agency has been provided documented proof of this person's high school diploma or equivalency?*
All background check requirements have been completed according to OAC 5123:2-2-02 including results and registry checks within the specific time frames*

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 Signature of Agency Employer/Designee

Ohio Department of Developmental Disabilities

Application for DD Personnel Medication Administration Certification


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

Personal Information

(not full number)
Date of birth*
Are you an Independent Provider?*
If yes, do you have:
(Must provide proof to RN Trainer)
Personel Address*

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?*

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

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

Use your mouse or finger to draw your signature above

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

(includes validation of HSD/GED for Independent Providers)

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