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City

State

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RN License Information

License Number I am a registered nurse with at least one year experience providing care for the elderly or chronically ill of any age.

Expires

Image of RN License

WORK EXPERIENCE VERIFICATION

Supervisor's Name Name of supervisor that will verify your one-year work experience providing care for the elderly or chronically ill of any age.

Facility Name Name of the supervisor's facility.

Facility Address

Facility City

Facility State

Facility Zip Code

REFERENCE

Reference's Name Name of reference that will certify the herein disclosed information is true and correct.

Reference's Email

Reference's Phone Number

RESUME

Resume Please upload your resume detailing your one-year work experience providing care for the elderly or chronically ill of any age.

TEST ADMINISTRATION SERVICES ENTITY (TASE)

TASE Testing Administration Services Business Name (Please complete the following fields for your Testing Administration Services Business Entity (TASE).

TASE Federal Identification Number (FEIN)

TASE Secretary of State ID #

TASE Contact Name (if different than RN Test Observer name)

TASE Phone # (if different than RN Test Observer phone number)

TASE Address (if different than RN Test Observer address)

TASE City (if different than RN Test Observer city)

TASE State (if different than RN Test Observer state)

TASE ZIP Code (if different than RN Test Observer ZIP code)

TASE Email (if different than RN Test Observer email)

TASE Website (optional)

IRS FORM W-9 Request for Taxpayer Information

IRS Form W-9 (must have your business name and your Federal Tax ID number on it and must be signed-there has to be a wet signature) Please complete the IRS W-9 form (link found in the directions and affidavit) and upload it with this application. IRS W-9 Form must have your business name and your Federal Tax ID number on it and must be signed (there has to be a wet signature).

DIRECT DEPOSIT FORM

Direct Deposit Form (must include a voided check or bank letter) Please complete the Direct Deposit Form (link found in the instructions and affidavit) and upload it with this document. Direct Deposit Form must include a voided check or bank letter. NOTE: This does not have to be a business bank account, we can electronically deposit your testing payments into any bank account.

Affidavit

CONFIDENTIALITY/NONDISCLOSURE:
I acknowledge the confidential nature of the nursing assistant competency examination. This includes the materials, processes, procedures, and content of both the knowledge and manual skills portions of the examination.

I agree to safeguard the confidentiality of all information about the nursing assistant competency examination.
I will not disclose any portion of the examination materials.
I will not disclose the processes or procedures necessary to administer or pass the examination.
I will not disclose any examination results to instructors or administrators of any training facility or program.
I will not test or be involved in testing students I have trained or had professional contact with during training, family members, or close personal friends.

I understand that this agreement extends to and includes, but is not limited to, allowing unauthorized persons to hear, view, videotape, or otherwise gain any knowledge about the exam before, during, or after the administration of an exam. I recognize that disclosing or revealing, or allowing this information to be disclosed or revealed constitutes a violation of this agreement and could place my nursing license at risk and/or be subject to prosecution to the full extent of the law and/or a $100,000 fine. I agree to immediately report any known or suspected breach in security relative to the nurse aide competency examination by calling the D&SDT-HEADMASTER home office at (800)393-8664.

ACTOR AND KNOWLEDGE TEST PROCTOR (KTP) TRAINING AFFIDAVIT:
I hereby swear that I, as a certified RN Test Observer, have provided and reviewed and will abide by the Actor training material and Knowledge Test Proctor training guidelines with any individual(s) I choose to use as an Actor or Knowledge Test Proctor. Click the following links to open the Actor Training Material and KTP Training Guidelines.

I attest that the individual(s) I choose to use as my Actor and/or KTP have completed the Actor and/or Knowledge Test Proctor (KTP) Training Affidavit and Confidentiality/Nondisclosure Agreement Applications available at https://oh.tmuniverse.com/apply
I also understand that any Actor or Knowledge Test Proctor I choose to use will not be able to sit for the Nurse Aide test for six (6) months from the date that I last used them as an Actor or Knowledge Test Proctor.

TEST SITE EQUIPMENT LIST AND RN TEST OBSERVER AFFIDAVIT (1503 OH): (Keep a copy of this form for your records.) Click on the 1503 OH Test Site Equipment List and RN Test Observer Affidavit to open the document.

I hereby certify that the test sites where I test will be checked before starting each test event to ensure that the test site equipment listed on the 1503 OH Form is available and in good working order. If not, I will report missing or inoperable test site equipment by listing it in TMU© under the test discrepancies before submitting my test event observations for scoring. I will carry at least the minimum equipment/supplies listed on the Additional Equipment Normally Provided by RN Observer to each test event I choose to manage.

TEST ADMINISTRATION SERVICES (TASE) AGREEMENT (1505 TASE): (Keep a copy of this agreement for your records.) Click on the 1505 TASE AGREEMENT FORM to open the document.
I hereby certify that I have read, understand, and will abide by the terms and conditions of the Testing Services Business Entity Agreement Form (1505 TASE) as established to do business by statute in the State of Ohio.

I understand that there is a one-time fee of one hundred dollars ($100.00) to certify that I have the necessary qualifications to administer exams that meet State testing standards.

I have uploaded the required documentation with this application, which includes:

Resume and copy of my RN License
Signed (with a wet signature) W-9 Form with my business name and Federal Tax ID
Direct Deposit Form with a voided check or bank letter

By Submitting

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

Application Fee $100.00

Non-Refundable. All fees are non-refundable.

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RN Test Observer | Test Administration Services Entity (TASE) Application Application