MEDICATION COURSE FOR RESIDENTIAL FACILITY
Ohio Department of Developmental DisabilitiesApplication for DD Personnel to Attend the DODD Medication Administration (MA) Certification CoursePrior 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.PAGE 1: Must be fully completed by employer Date of Application: _____________ DATE AND CLASS YOU WANT TO ATTEND:_________________________________ 4280535129540003403600136949002607310136525001845734136949a00a114215413462000Method Payment: Cash Check PayPal E-check Bill my agencyDD Personnel: (print) Agency Employer? FORMCHECKBOX OR DODD Certified Independent Provider? FORMCHECKBOX 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? FORMCHECKBOX At the address listed above OR FORMCHECKBOX 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-mailSUPERVISOR: 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 FORMCHECKBOX YESStart Date: ______________________This person at least 18 years of age: FORMCHECKBOX YESThe agency has been provided documented proof of this person’s high school diploma or equivalency? FORMCHECKBOX 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 FORMCHECKBOX YESAs 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 )DODD 08/01/2013 ................
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