FACILITY ACKNOWLEDGEMENT:
- I certify that I am working as a proctor for the in-facility site named in this application.
- I understand that I will administer the nurse aide competency tests as a regular part of my duties with the in-facility site named in this application without compensation from HEADMASTER.
- I certify that nurse aide candidates testing or any volunteer test subjects used will be facility employees and/or residents.
CONFIDENTIALITY/NONDISCLOSURE:
I acknowledge the confidential nature of the nursing assistant competency examination. This includes the materials, processes, procedures, and content of the examination's knowledge and manual skills portions.
- 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, 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:
As a certified RN Test Observer, I verify that I have provided and reviewed and will abide by the Actor training 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 Guidelines 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://nd.tmutest.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 ND): (Keep a copy of this form for your records.) Click on the 1503ND Test Site Equipment List to open the document. I hereby certify that the in-facility test sites where I test will be checked before starting each test event to ensure that the test site equipment listed on the 1503ND 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 for each test event I manage.
I am confirming that I have read, understood, and will follow the terms and conditions of this Agreement Form.
- I understand that I must pay a one-time fee of $89.95 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
- Copy of my RN License
I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.