Application Form For Personnel Medication Administration Page 2
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1
2Ohio 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: DD Personnel are required to complete this application, including
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:
Category 1- Medication Administration
Category 2- G/J Tube Medications
Category 3 - Insulin
Category 1 Renewal
Category 2 Renewal
Category 3 Renewal
Have you ever taken a medication administration certification class before this application?
YES
NO
PRINT:
Last Name
First Name
Middle Initial:
Last four digits of social security number: ____ ____ ____ ___
(not full number)
Date of Birth:
/
/
Gender:
Female
Male
Are you an Independent Provider?
YES
NO
If yes, do you have:
(
)
High School Diploma or
High School Equivalency Document
must provide proof to RN Trainer
Personal Address:
City:
State:______________
Zip:
County:
Home: (_____)
Work :(_____)
Cell :(_____)
Personal E-mail:
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 print the names and Provider Number of all DD employers you currently work for:
DD Employer:
Provider #
DD Employer:
Provider #
I attest that all information provided on this application is true, current, and correct.
Date:
Signature of DD Personnel
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
(includes validation of HSD/GED for Independent Providers)
Date
Session # (If Initial Certification – not renewal)
(Page 2 of 2)
DODD 8/1/2013
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