Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62586 (Rev. 10/08)

STATE OF WISCONSIN

CHALLENGE EXAM APPLICATION FOR NURSE AIDE / MEDICATION AIDE
This application reports the successful completion of a Wisconsin approved medication aide training program by a nurse aide previously included on the Registry. Successful completion of the medication aide training program allows a nurse aide to administer medications in a federally certified skilled nursing home. The personal information will only be used to determine your nurse aide employment eligibility. This application will not be processed if it is incomplete, unsigned or illegible. Questions about completion of this form may be directed to 608-266-5388. SUBMIT THE FOLLOWING ITEMS WITH THIS APPLICATION: Letter of recommendation from DON, Nursing Home Administrator, and two (2) Charge Nurses. Transcripts that document medication administration courses attended (if applicable). Certification of Med Aide from another state and criteria to be a Med Aide in that state (if applicable). SUBMIT ALL MATERIALS TO: Division of Quality Assurance ATTN: Pharmacy Consultant P.O. Box 2969 Madison, WI 53701-2969

APPLICANT INFORMATION
Name ­ Applicant Birth Date Mailing Address Name ­ Employer Address ­ Employer Preferred Testing Location Registration Number Telephone Number (Home) City Date Application Completed Telephone Number (Work) State Zip Code

RELEASE I authorize

_____________________________ or its appointed representative, to release the information on this
_________________________________ , or its

form to the Wisconsin Nurse Aide Directory. I also authorize

representative, to release necessary information regarding my performance in the Nurse Aide / Medication Aide course to my current employer or any future prospective employer. SIGNATURE ­ Applicant
Date Signed

VERIFICATION I have verified this applicant's background and have determined that the applicant is: Eligible Not Eligible for Challenge Testing. The applicant is required to participate in the following: Final Exam Practicum Exam SIGNATURE ­ Pharmacy Consultant
Title Date Verified