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Certified Medication Aide I Challenge- Nursing Students Application

Legal First Name

Middle

Legal Last Name

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Birthdate

Phone

SSN

Gender

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Address

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Section II

Are you currently listed on the Kentucky Nurse Aide Registry?

I am:

Current employment as a SRNA or CMA? List company name and address

Section III

Nursing School Attended:

Dates Attended:

Dean of Nursing:

Dean of Nursing Phone:

Dean of Nursing Email:

Select the option that best describes your situation. I have successfully completed:

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Official Transcript- Nursing Students

Course Syllabus-Nursing Students ***If your pharmacology class did not include a clinical rotation in a healthcare facility, please include the syllabus from the nursing course completed that included the opportunity to perform medication passes in a healthcare facility during a clinical rotation.

Verification of active nurse aide registry status with KY Board of Nursing

Proof of 6 Month Employment as SRNA

Additional Proof of 6 Month Employment as SRNA (if needed)

Affidavit

I have attached ALL required documentation as requested for verification to determine eligibility to challenge the Certified Medication Aide I examination.

If approval to test is received, the exam fee of $50.00 and scheduling is handled through the TMU system.

By Submitting

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