Form 5503, 2007, Verification Of Curriculum By An Accredited School Of Nursing printable pdf download

Form 5503, 2007, Verification Of Curriculum By An Accredited School Of Nursing

Texas Department of Aging

Form 5503-MA

and Disability Services

August 2007

Medication Aide Program

Verification of Curriculum

by an Accredited School of Nursing

The Texas Department of Aging and Disability Services (DADS) requests verification that the courses taken by this student (a

medication aide applicant) meet the requirements as specified in TAC 95.107(c)(2) of the Medication Aide Training Program rules. Use

the Nursing Home Medication Aide Training Program Basic Course Curriculum to determine this eligibility.

Applicant

Name of Applicant (Last, First, Middle)

Maiden Name (if applicable)

Address (Street or P.O. Box)

City

State

ZIP Code

Name of Nursing School

Address (Street or P.O. Box)

City

State

ZIP Code

Dates Attended (mm/dd/yyyy):

From:

To:

Nursing School Administrator

The administrator of the accredited school of nursing is responsible for determining that the courses to which he or she certifies cover

the department’s curriculum.

, certify that the above named student meets the requirements included in

the DADS Nursing Home Medication Aide Training Program Basic Course Curriculum.

I agree that DADS may investigate this information.

List names and numbers of the courses meeting the requirements:

Place School

Signature — Nursing School Administrator

Seal Here

Date (mm/dd/yyyy)

Mail to:

Medication Aide Program

P. O. Box 149030

Mail Code E-416

Austin, Texas 78714-9030

E-mail Address:

credential@dads.state.tx.us

Form 5503, 2007, Verification Of Curriculum By An Accredited School Of Nursing