Submit New Application

IN-FACILITY RN TEST OBSERVER AGREEMENT Application

Please fill out this application if you are applying to be an RN Test Observer who will administer the Medication Aide I & II competency tests as a regular part of your duties with the IN-FACILITY named in this application with no compensation from HEADMASTER.  Include the following uploads: 
  • An updated resume detailing your one-year experience providing care for the elderly or chronically ill of any age.
  • A copy of your RN Nursing License 
There is a one-time fee of $50 to certify that you have the necessary qualifications to administer exams that meet State testing standards. Please complete the credit/debit card certification fee payment information when you submit this application.

Once you have completed all the fields and uploaded the required documents within this application, select 'Send Application' to submit your application. 
Address
RN License Information
WORK EXPERIENCE VERIFICATION
REFERENCE
RESUME
Affidavit
FACILITY ACKNOWLEDGEMENT:
  • I certify that I am working as a proctor for the in-facility named in this application.
  • I understand that I will administer the Medication Aide I & II competency tests as a regular part of my duties with the in-facility named in this application, with no compensation from HEADMASTER.
CONFIDENTIALITY/NONDISCLOSURE:
I acknowledge the confidential nature of the Medication Aide I & II competency examinations, including the materials, processes, procedures, and content of the knowledge exam. 
  • I agree to safeguard the confidentiality of all information about the 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 competency examination by calling the D&SDT-HEADMASTER home office at (800)393-8664.

I hereby certify that I have read, understood, and will abide by the terms and conditions of this Agreement Form.  
  • I understand that I must pay a one-time fee of $50 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
By Submitting
I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.
Application Fee $50.00
Non-Refundable. All fees are non-refundable.
1.800.393.8664