Initial Medication Assistant I & Ii Application - North Dakota Department Of Health
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INITIAL MEDICATION ASSISTANT I & II APPLICATION
Class Roster Match with app
North Dakota Department of Health
Yes ____
No ____
Division of Health Facilities
SFN 59962 (R2-2012)
Medication Assistant I - Must be an NA or CNA - (Non-Refundable Fee $25.00)
Please Check One
Medication Assistant II - Must be a CNA - (Non-Refundable Fee $25.00)
PLEASE CHECK THE REGISTRY CATEGORY YOU CURRENTLY HOLD:
Certified Nurse Aide (CNA):Registry Number _______________
Expiration Date ___________________
Nurse Aide (NA) Registry Number _______________________
Expiration Date ___________________
APPLICANTS, PLEASE COMPLETE ALL INFORMATION BELOW (Please print legibly)
First Name
Last Name
Maiden/Middle Initial
M
F
Current Mailing Address (Include C/O Address)
County
City
State
Zip Code
Social Security Number (Required)
Date of Birth
E-Mail Address
Home Phone
Work Phone
Cell Phone
Name of Employer
City
State
Employer’s Contact Name
Employer’s Phone Number
ALL QUESTIONS BELOW MUST BE COMPLETED BY APPLICANT
Have you ever been arrested, charged, or convicted of a felony (You must answer yes if the felony arrest
or felony charge resulted in a plea agreement, misdemeanor, nolo contendere, deferred imposition, or
1.
Yes
No
other action) within the last two years?
No
Has your registration or nursing license been sanctioned or disciplined by any other jurisdiction?
2.
Yes
Have you had a nurse aide registry listing or unlicensed assistive person registry listing marked
3.
Yes
No
for abuse, neglect, or misappropriation of property?
Have you been investigated or are you presently being investigated by any other jurisdiction?
4.
Yes
No
Have you been denied registration or licensure by any other jurisdiction?
5.
Yes
No
Have you, in the last two (2) years, been terminated from a nurse aide or nursing related job
No
6.
Yes
due to conduct that may be grounds for disciplinary action?
Have you, in the last two (2) years, been diagnosed with chemical dependency or participated in
7.
Yes
No
chemical dependency treatment/rehabilitation?
Have you, in the last two (2) years, been diagnosed with or treated for a mental health or
8.
Yes
No
physical condition which adversely affected your ability to safely provide nurse aide services?
If you answered “Yes” to any of the above questions, please attach a detailed written explanation and any
legal documents to the application and send to the North Dakota Department of Health for review.
9.
Yes
No
NA
Have you attached the appropriate documents?
APPLICATION CERTIFICATION
I certify the information provided is true, correct, and complete, and I understand that submission of any false or incomplete
information may be grounds for disciplinary action.
Applicant Signature
Date
Date Received ____________
Amount Received $__________
Cash MO or CK#_________
FOR STATE USE ONLY
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