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MEDICATION AIDE: RN Test Observer | Test Administration Services Entity (TASE) Application

Please fill out this application if you are an active Nurse Aide Test Administration Service Entity and would like to also administer Medication Aide exams.

You will attest in the Affidavit at the end of this document that you have read, understand, and will abide by the following documents.  Please print these documents and keep them for your records.
Once you have completed all the fields and uploaded the required documents within this application, select 'Send Application' to submit your application. 

*If you ARE NOT a Nurse Aide TASE and would like to administer Medication Aide exams, please call (888) 401-0462*
Address
RN License Information
Affidavit
 CONFIDENTIALITY/NONDISCLOSURE:
I acknowledge the confidential nature of the medication assistant competency examination, including the materials, processes, procedures, and content of the knowledge exam. 
  • I agree to safeguard the confidentiality of all information about the medication 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.

Optional, if you use a KTP- (KTP) TRAINING AFFIDAVIT:
As a certified RN Test Observer, I swear that I have provided and reviewed and will abide by the Knowledge Test Proctor training guidelines with any individual(s) I choose to use as a Knowledge Test Proctor.   Click the following link to open the KTP Training Guidelines.
  • I attest that the individual(s) I choose to use as my KTP have completed the Knowledge Test Proctor (KTP) Training Affidavit and Confidentiality/Nondisclosure Agreement Application available at https://wy.tmutest.com/apply
  • I also understand that any Knowledge Test Proctor I choose to use will not be able to sit for the Medication Aide test for six (6) months from the date I last used them as a Knowledge Test Proctor.
I hereby certify that the test sites where I test will be checked before starting each test event to ensure that the area is distraction—and interruption-free and that any equipment (e.g., computers/laptops, internet) 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. 

TEST ADMINISTRATION SERVICES (TASE) AGREEMENT (1505MA TASE):  (Keep a copy of this agreement for your records.)  Click on the 1505MA TASE AGREEMENT FORM to open the document.
I hereby certify that I have read, understood, and will abide by the terms and conditions of the Testing Services Business Entity Agreement Form (1505MA TASE) as established by statute in the State of Wyoming to do business.  
  • I am a Nurse Aide TASE with D&SDT-HEADMASTER
By Submitting
I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.
1.800.393.8664