Medication Aide Training Program

License Selection

Select the Board for which you are seeking a license.

Next, select the license type, individual license, and application type.

Select a Board

Nursing Board

Select a License

Medication Aide (MA-C)

Select an Application Type

General Application

Eligibility

By answering the following questions, eligibility for the license application will be determined. Confirmation will be noted if eligibility is met.

Are you at least 18 years of age?

Yes No

Do you have a high school diploma or GED?

Yes No

Application Instructions

Provide the information necessary for the license

application. Once finished, click which type of Save option desired.

MEDICATION AIDE APPLICATION INSTRUCTIONS

Application Instructions

A list of “Approved Medication Aide Training Programs” can be found under the Medication Aides link on the Board’s website.

1. Non-Refundable Application Fee

A $50 non-refundable fee must accompany this

application and will be processed electronically.

2. Form A - Program Completion

To download Form A, click on the Medication Aides link on the Board’s website. Part 1 must be completed by the applicant and sent to the medication aide training program. Part 2 must be completed and submitted

directly to the Board by the training program

representative. Form A will not be accepted from the applicant.

3. Board Approved Examination Test Results

Verification of passing a certification examination must be sent directly to the Board by the national

testing/certifying organization or by the Medication Aide Training Program. Please note: (within 60 days of satisfactorily completing the required classroom and supervised clinical practice components, the student shall take a board approved examination).

4. Criminal Records Check

Refer to the website for more information.

http://www.nursing.ohio.gov/pdfs/CRC_Process.pdf

(http://www.nursing.ohio.gov/pdfs/CRC_Process.pdf) Processing Information

It is your responsibility to ensure that all required documents are received by the Board directly from the appropriate agency.

To determine the status of your application, please go to the Board’s website at www.nursing.ohio.gov

(http://www.nursing.ohio.gov/), click on “Verify a MEDICATION AIDE APPLICATION

2017

SAMPLE ONLY

(Not for Submission)

License or Certificate” and enter your name. Once your name appears, it will display as “pending” until your medication aide certificate is issued.

The application is void and the fee is forfeited if the requirements for a medication aide certificate are not met within one year from the date the application is received by the Board.

For questions about the application or instructions, please email ***************@*******.****.***

(mailto:***************@*******.****.***).

CANCEL SAVE AND CONTINUE

MEDICATION AIDE APPLICATION

2017

SAMPLE ONLY

(Not for Submission)

New License Application

Personal

Information

Background Questions Attachments Review + Submit

Personal

Information

Provide the necessary personal

information in the fields to the

right. All fields with are

required and must be completed

to continue the application

process.

Title

*

First Name

Middle Name

*

Last Name

Maiden Name

* Social Security Number

*

Date of Birth

*

Email Address

*

Phone Number

Other Phone Number

*

Citizenship

Additional

Information Do you have other aliases?

MEDICATION AIDE APPLICATION

2017

SAMPLE ONLY

(Not for Submission)

Provide the necessary additional

information in the fields to the

right. All fields with are

required and must be completed

to continue the application

process.

*What is your gender?

What is your ethnicity?

*

In which country were you born?

In which state were you born (if United States)?

In which city were you born?

License Mailing

Address

Select a license mailing address

by clicking the appropriate

checkbox to the right (this is the

address used for all postal

communications from the Board

for this license). To add a new

address, click Add Address,

complete the required fields, and

click Save.

Mailing Address

17 S High St

Ste 400

Columbus OH 43215-

3413

Franklin

United States

+ ADD ADDRESS SAVE AS MAILING

Military Service

If you have served in the military,

provide the information for the

type of service and duration of

the service. Also, provide proof

of your service.

*

Have you served in the military?

*

Has your spouse served in the military?

MEDICATION AIDE APPLICATION

2017

SAMPLE ONLY

(Not for Submission)

SAVE & FINISH LATER SAVE AND CONTINUE

Country of Service

Service Branch

Are you still serving in the military (Active or Reserve)? Were you honorably discharged from your service?

Service Start Date

Service End Date

MEDICATION AIDE APPLICATION

2017

SAMPLE ONLY

(Not for Submission)

New License Application

Personal

Information

Background Questions Attachments Review + Submit

SAVE & FINISH LATER SAVE AND CONTINUE

Education History

INSTRUCTIONS:!Please provide

information related to your medication aide

training program AND your high school or

GED information. To add an entry to your

education history, click the ADD EDUCATION

button. Begin by typing “Other” into the

Education Institution field. In the Other

College/University field directly below

enter the name of your high school or GED

program. Enter the requested information for

all education entries. In the Degree Type field

select High School or GED. All fields marked

with are required. Once finished, continue

with the next Background sections or click the

SAVE AND CONTINUE button.

* Other

Education Institution

Other College/University

Other College/University Address

Select One

Educational Program Degree Type

* Degree Received

*

Enrollment Date

*

Graduation Date

CANCEL ADD

MEDICATION AIDE APPLICATION

2017

SAMPLE ONLY

(Not for Submission)

New License Application

Personal

Information

Background Questions Attachments Review + Submit

FILE A COMPLAINT

Questions

Answer the following questions by selecting

the Yes/No option for each question. Once

completed, click Save Answers.

Do you have at least one year of direct care experience in a residential care facility?

Yes No

Are you a state tested nurse aide in Ohio?

Yes No

Have you EVER been convicted of, found guilty of, pled guilty to, pled no contest to, pled not guilty by reason of insanity to, entered an Alford plea, received treatment or intervention in lieu of conviction, or been found eligible for pretrial diversion or a similar program for any of the following crimes.This includes crimes that have been expunged IF there is a direct and substantial relationship to function as a Medication Aide? A felony in Ohio, another state, commonwealth, territory, province, or country?

Yes No

If yes to previous question - Was the felony any of the following: aggravated murder, murder, voluntary manslaughter, felonious assault, kidnapping, rape, sexual battery, gross sexual imposition, aggravated arson, aggravated robbery, or aggravated burglary?

Yes No

Was the felony a drug offense?

Yes No

Have you EVER been convicted of, found guilty of, pled guilty to, pled no contest to, pled not guilty by reason of insanity to, entered an Alford plea, received treatment or intervention in lieu of conviction, or been found eligible for pretrial diversion or a similar program for any of the following crimes. This includes crimes that have been expunged IF there is a direct and substantial relationship to function as a Medication Aide? A misdemeanor in Ohio, another state, commonwealth, territory, province, or country? This does not include traffic violations unless they are DUI/OVI or Physical Control While Under the Influence. Yes No

TESTER, TESTA

MEDICATION AIDE APPLICATION

2017

SAMPLE ONLY

(Not for Submission)

Have you been found to be a mentally ill person subject to hospitalization by court order, been found to be mentally incompetent by a probate court, or been found incompetent to stand trial by a court?

Yes No

Has any board, bureau, department, agency or other body, including those in Ohio, other than this board, in any way limited, restricted, suspended, or revoked any professional license, certificate, or registration granted to you; placed you on probation; or imposed a fine, censure, or reprimand against you? Have you ever voluntarily surrendered, resigned, or otherwise forfeited any professional license, certificate, or registration?

Yes No

Have you ever, for any reason, been denied an application, issuance, or renewal for licensure, certification, registration, or the privilege of taking an examination, in any state (including Ohio), commonwealth, territory, province, or country? Yes No

Have you ever entered into an agreement of any kind, whether oral or written, with respect to a professional license, certificate, or registration in lieu of or in order to avoid formal disciplinary action with any board, bureau, department, agency, or other body, including those in Ohio, other than this Board? Yes No

Have you been notified of any current investigation of you, or have you ever been notified of any formal charges, allegations, or complaints filed against you by any board, bureau, department, agency, or other body, including those in Ohio, other than this Board, with respect to a professional license, certificate, or registration? Yes No

Have you ever been diagnosed as having, or have you been treated for, pedophilia, exhibitionism, or voyeurism?

Yes No

Within the last five years, have you been diagnosed with or have you been treated for bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder? Yes No

Have you, since attaining the age of eighteen or within the last five years, whichever period is shorter, been admitted to a hospital or other facility for the treatment of bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder?

Yes No

Are you currently engaged in the illegal use of chemical substances or controlled substances? For this question “Currently” does not mean on the day of, or even weeks or months preceding the completion of this application. Rather, it means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a certificate holder or licensee, or within the past two years. “Illegal use of chemical substances or controlled substance” means the use of chemical substances or controlled substances obtained illegally (e.g. heroin, cocaine, or methamphetamine) as well as the use of controlled substances, which are not obtained pursuant to a valid prescription, or not taken in accordance with the direction of a licensed healthcare practitioner.

Yes No

MEDICATION AIDE APPLICATION

2017

SAMPLE ONLY

(Not for Submission)

SAVE & FINISH LATER SAVE AND CONTINUE

SAVE ANSWERS

If you answered “Yes” to the previous question, are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you in order to assure that you are not illegally using chemical substances or controlled substances?

Yes No

Are you required to register, under Ohio law, the law of another state, the U.S., or a foreign country, as a sex offender?

Yes No

MEDICATION AIDE APPLICATION

2017

SAMPLE ONLY

(Not for Submission)

New License Application

Personal

Information

Background Questions Attachments Review + Submit

SAVE & FINISH LATER SAVE AND CONTINUE

Attachments

If applicable, upload the Attachments for your

license application by clicking the Add

Attachment button(s). If uploading an

attachment as a submission, it is necessary

that the name of the file attachment is less

than 80 characters in length for it to be

received successfully. The character limit

does include the file attachment extension,

such as (.doc) and (.pdf). For documentation

that needs to be submitted directly to the

Board or by hardcopy, please acknowledge by

clicking the Attest button(s). If no attachment

or attestation items appear, please click the

Save and Continue button.

BCI/FBI Background Check

Form A - Program Completion

Board Approved Examination Test Results

I acknowledge that I will complete BCI and FBI background checks.

ATTEST

I acknowledge that the medication aide training program must send Form A directly to the Board.

ATTEST

I acknowledge that my certification examination results must be sent directly to the Board by the testing organization or the training program.

ATTEST

MEDICATION AIDE APPLICATION

2017

SAMPLE ONLY

(Not for Submission)

New License Application

Personal

Information

Background Questions Attachments Review + Submit

Application Review

Completed

Attestation

Your social security number is required by state and federal law for purposes of child support enforcement (ORC 3123.50, 42 U.S.C. Section 666), reporting to the National Practitioner Data Bank (Public Law 100-93, Sec. 1921 of the Social Security Act, as amended; 45 C.F.R. pt. 60); reporting to law enforcement authorities for investigative/law enforcement purposes in compliance with ORC 4723.28, and/or as otherwise required by state and federal law. I am the person in this application for Certification and the statements made herein are true and accurate. I hereby request that in order to process my application, act upon renewal requests, and respond to public requests to confirm my certificate status, my personal information be accessed in accordance with OAC 4723-1-11 (D)(2)(d)(ii). I have read and understand this Attestation and consent for fingerprinting. Consent to Electronic Signature

Type your First Name and Last Name as they appear on the application to sign electronically.

(Testa Tester)

I accept

Submit your

Application

After clicking the ‘Submit’ button below, you will no longer be able to change this application. PLEASE DO NOT USE THE BROWSER'S BACK BUTTON AS THAT MAY OVERWRITE YOUR DATA. If you want to return to your application, simply log out and log back in. If this application requires payment you will be prompted to begin the payment process. You must complete the payment process before the board will review your application. If this application does not require payment, you will be navigated back to the eLicense home page and the board will review your application.

SAVE & FINISH LATER SUBMIT

MEDICATION AIDE APPLICATION

2017

SAMPLE ONLY

(Not for Submission)

Contact this candidate