Application Form For Personnel Medication Administration
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1
2Ohio 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:
Agency Employer?
OR
DODD Certified Independent Provider?
If you are a DODD Certified Independent Provider, for purposes of this application, you are the employer.
EMPLOYER:
DODD PROVIDER NUMBER:
WORK LOCATION: At the time of this application, where does this person primarily provide services or supervision?
At the address listed above
OR
Other agency location - Address:
_____________________________________________________
______________
Work Location Phone: ____________________
___
E-mail:_____________________
_______
(If no direct phone or e-mail at location, list DD employer agency phone and e-mail
SUPERVISOR: At the time of this application, who is the direct supervisor of this DD personnel?
Print Name & Title of direct supervisor:
____________________________________________________________
Phone for direct supervisor: ________________________
E-mail for direct supervisor:
_____________________
.
When did this supervisor begin supervision of this DD personnel? Date:
_____________________
Please verify all of the following are true as of the date of this application:
•
This person is employed by the agency
YES
Start Date: ______________________
•
This person 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 specified 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.
Print
Name & Title of Agency Employer/Designee
_____________________________________________________________ Date:
Signature of Agency Employer/Designee
(Page 1 of 2)
DODD 8/1/2013
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