Account Applications Create

Address

City

State

Zipcode

Mailing Address

Address

City

State

Zipcode

Additional Facility Information

Discipline Select the discipline type you are applying for.

Parent Facility Select the parent facility for this facility.

If applicable- Primary College Name:

If applicable- Satellite Name:

If applicable- Satellite Address:

If applicable- Satellite City:

If applicable- Satellite State:

If applicable- Satellite Zip Code:

EXAM COMPONENTS TESTED

Please select from the drop-down list the exam component option that your site will supply an approved area to test nurse candidates:

TESTING TEAM TYPE

Please select from the drop-down list the type of certified testing team your test site will use for testing that fits your testing needs and test site availability:

SKILL TEST BILLING STATUS

Please select your site's skill test billing status from the drop-down list: Payment to D&SDT-HEADMASTER for using the TMU© software test administration platform and other selected services are as follows: $23- per knowledge/oral test administered -or- $30/hour- for remotely proctored knowledge test if skill only is selected in the EXAM COMPONENTS TESTED section or if using a CERTIFIED RN TEST OBSERVER AND CERTIFIED TEST TEAM FROM THE STATEWIDE POOL OF CERTIFIED TEST TEAMS in the TESTING TEAM TYPE section. (NOTE: In order to change your skill test billing status, please submit a new TEST SITE APPLICATION.)

IMAGES OF TEST SITE (and Satellite Sites if applicable)

Upload images of the test site layout, knowledge test room (if your site does on-site knowledge exam testing), the skills lab layout, equipment and supplies: Please upload images of your test site room layout(s.) Include images of the skills lab layout, equipment, and supplies.

DIRECTIONS TO TEST SITE

Additional Directions: Candidates receive a confirmation letter with the address of your facility upon scheduling. If you have any additional directions for how to get there or where to go once they arrive, please provide that information here. (For example, landmarks to look for, parking lot to use, building number, entrance number, floor and room number, or any other directions that help candidates get to your test site.)

Optional: LARGE LAB WAIVER REQUEST [when requesting approval for two simultaneous test events in one large area]

Name of Test Site Waiver Requestor:

Email for Test Site Waiver Requestor:

Phone number for Test Site Waiver Requestor:

Upload images of blue prints of the room/area or scale drawing showing the layout of the room/area and; where the two sets of TEST SITE EQUIPMENT LIST equipment items will be located within the two separated testing areas: Helpful things that must be included with this waiver request:  On the blue print or drawing, show the traffic flow for ingress and egress into and out of the two separated skill test areas, and;  Show the path from the bed(s) to separate sink – commode areas.  Show the anticipated location of the equipment and supplies for each area.  Show the location of two equipment and supplies tables and two relaxation areas. (Two chairs side-by-side where the instructions are read to the candidate upon entering the testing area.)  Convey how visual separation between the two areas will be maintained.  List how audio separation will be dealt with. (Curtains, white noise machine, acoustical considerations, sight lines.)  Pictures showing the area(s) as it/they would look like/be set up during testing

IF NEEDED: you may add additional narrative information regarding your Large Lab Waiver Request:

Affidavit

TEST SITE AGREEMENT: (Keep a copy of this form for your records.)

I hereby agree to and understand that our Facility will allow Nurse Aide Knowledge and/or Skill Tests to be administered under the guidelines in the Test Site Agreement.
I certify that our site is not under authoritative sanctions, and I have read, understood, and will abide by all listed guidelines in the Test Site Agreement.

TEST SITE EQUIPMENT LIST: (Keep a copy of this form for your records.)

I hereby certify that our Facility has the equipment, supplies, and room requirements (or double the equipment for waiver request test sites) listed in the Test Site Equipment List and will make the equipment and supplies available to certified RN Test Observers for the purpose of administering nurse aide knowledge and skill tests to nurse aide candidates at our test site for days we have scheduled test events in TMU©.
- I have uploaded images of my test site layout, knowledge test area (if applicable), skills test layout, equipment, and supplies.

CREDIT TERMS: I have applied for PO/credit terms with D&SDT-HEADMASTER’s accounting department via the Credit Authorization Application.

I understand that if payments become delinquent, I will have to pay in advance for further test scheduling privileges using the TMU© testing platform.

SKILL TEST BILLING STATUS:

I understand that in order to change my skill test billing status, I will have to submit a new TEST SITE APPLICATION.)

OPTIONAL LARGE SKILL LAB WAIVER (if applicable):

I have completed the LARGE LAB WAIVER REQUEST section, including supplying all information and uploading the required images.

By Submitting

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

Submit New Application

TEST SITE Application