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NURSE AIDE & MEDICATION AIDE: TEST SITE Application

Please complete this application to become an approved Test Site. Attach pictures of your test site knowledge exam test room layout (if your site does on-site knowledge exam testing), the skills lab room layout, equipment, and supplies for review. In the Affidavit at the end of this document, you will attest that you have read, understood, and will abide by the following documents, and you have attached the required test site images. Please print these documents and keep them for your records.

Test Site Agreement
Test Site Equipment List (the equipment, supplies, and room requirements that must be available and in good working order to be a test site)

Once you have completed all the fields in this application and uploaded the required images, select “Send Application" to submit it.

Name

Fax

Phone

Alt Phone

Administrator

Address

City

State

Zipcode

Mailing Address

Address

City

State

Zipcode

Additional Facility Information

Discipline Select the discipline type you are applying for.

Parent Facility Select the parent facility for this facility.

Test Site Type

Choose which type of Test Site you would like to be: The Test Site Agreement has two options to consider when becoming a Test Site. Please refer to it to choose which type of Test Site your facility will be.

Candidate Directions

Additional Directions: Candidates receive a confirmation letter with the address of your facility upon scheduling. If you have any additional directions for how to get there or where to go once they arrive, please provide that information here. (For example, landmarks to look for, parking lot to use, building number, entrance number, floor and room number, or any other directions that help candidates get to your test site.

Test Site Images

Upload images of the test site knowledge test room (if your site does on-site knowledge exam testing), the skills lab layout, equipment and supplies. Please upload images of your test site room layout(s.) Include images of the skills lab layout, equipment, and supplies.

Affidavit

TEST SITE AGREEMENT: (Keep a copy of this form for your records.)

I hereby agree to and understand that our Facility will allow Nurse Aide Knowledge and Skill Tests to be administered under the guidelines in the Test Site Agreement.
I certify that our site is not under authoritative sanctions, and I have read, understood, and will abide by all listed guidelines in the Test Site Agreement.

TEST SITE EQUIPMENT LIST: (Keep a copy of this form for your records.)

I hereby certify that our Facility has the equipment, supplies, and room requirements listed in the Test Site Equipment List and will make the equipment and supplies available to certified RN Test Observers for the purpose of administering nurse aide knowledge and skill tests to nurse aide candidates at our test site for days we have scheduled test events in TMU©.

By Submitting

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.