Application for CNA and Med Tech - Maryland

1 1 Application for CNA/MT Initial and Renewal I am a: CNA Applying for: Initial Cert No.: _____ Medication Tech Renewal Name:_____ _____Last Name First Name :_____ _____ _____ City State Zip code Security Number:Date of Birth: _____ Phone Number:Email Address: _____ _____ Section I. To be completed by Medication Technician Renewal Applicants Only Practice Requirements (Med Techs ONLY): 5. Have you practiced 100 hours as a certified Medication Technician in the last 1-2 years?Yes No 6. Have you completed the required clinical update1Fi in the last 90 days?

2 Yes No STATE OF MARYLAND2 Date Completed: _____ Name of Instructor: _____ 7. Have you repeated the 20 hour Medication Technician Training Program2 Fii in place of clinical update? Yes No Date Completed: _____ Name of Instructor: _____ of Supervising RNI have verified Section I of this form and affirm that the applicant s responses are true and correct. I also understand that providing false or misleading information to the Board may result in disciplinary action against my license _____ _____ Print Name Signature License No.: _____ Date: _____ _____ Section II.

3 To be completed by CNA Renewal Applicants ONLY Practice Requirements (CNA Renewal Applicants ONLY) 9. Have you worked as a nursing assistant for at least 16 hours in the last two years?Yes No Health AideHave you satisfactorily completed 12 hours of in-service training required by CFR, Section , within the past 12 months? Yes No B. Dialysis TechnicianHave you completed 16 hours as a dialysis technician in the past two years as well as one 3 hour Board approved continuing education course? Yes No nursing AssistantHave you practiced 8 hours, for compensation, in a licensed comprehensive care facility in the last two years?

4 Yes No HealthAre you currently practicing in a school health setting as a nursing assistant ? Yes No 3 E. DDAAre you currently practicing in a DDA setting as a nursing assistant ? Yes No F. certified Medicine AideHave you completed the required clinical update in the last 90 days? Yes No Have you practiced 100 hours as a certified medicine aide in the last 2 years? Yes No _____ Section III. To be completed by CNA Endorsement Applicants ONLY3 Fiii 10. Education VerificationName and Location of Training Program (Attach copy of certificate):_____Date Training Program was completed:_____11.

5 Prior or Current you ever been certified or are you currently certified as a nursing assistant in anotherstate? Yes No If yes, which state(s) _____ you ever been licensed as an RN/LPN in another state?Yes No If yes, which state(s) _____ C. Have you ever been certified as a nursing assistant by the MD Board of nursing ?Yes No If yes, do not continue, call/email the Board immediately D. Have you ever been licensed as an RN/LPN by the MD Board of nursing ?Yes No 4 12. Practice RequirementsA. certified nursing AssistantHave you worked as a nursing assistant 16 hours in the last 2 years?

6 Yes No B. Home Health AideHave you satisfactorily completed 12 hours of in-service training required by CFR, Section , within the past 12 months? Yes No C. Dialysis TechnicianHave you completed 16 hours as a dialysis technician in the past two years as well as one 3 hour Board approved continuing education course? Yes No D. Geriatric nursing AssistantHave you practiced 8 hours, for compensation, in a licensed comprehensive care facility in the last two years? Yes No _____ Section IV. To be completed by Initial Applicants for CNA Certification5Fv 13.

7 Education Verification To be completed by Training Program (including military and nursing education programs) Name and location of training program: _____ _____ Date Training Program was completed: _____ 14. Practice RequirementsA. Dialysis TechnicianDid you complete a Board approved dialysis technician training program? Yes No B. School HealthDid you complete a Board approved school health training program? Yes No C. DDA5 Did you complete a Board approved DDA training program? Yes No 15. Certification of Training Program (Certification not required for military or nursing education programs)It is hereby certified that _____ has completed_____ s certified nursing assistant program, located in _____ on _____.

8 It is further certified that the program was approved by the MD Board of nursing at the time applicant completed the program, and the applicant demonstrated oral competence in the English language and that his/her academic and professional standing during his/her program was satisfactory to the officers of this school. _____ _____ Signature of Program Instructor Date _____ Section V. To be completed by ALL APPLICANTS Have you ever been convicted of or plead guilty or nolo contendere (includes a guilty plea with PBJ)Yes to a misdemeanor: a felony : Yes No No B.

9 Has there been any disciplinary action taken against your license or certificate issued in anystate, including Maryland ? Yes NoC. If you currently hold a Maryland Medication Tech or nursing assistant Certificate, do any ofth e above apply since your last renewal? Yes No If you answered Yes to any of the above questions, a complete explanation is required upon submission of this Application ; along with any court documents showing the outcomes of your cases. Your Application is considered incomplete until these documents are submitted _____ Section VI.

10 To be completed by Initial and Endorsement Applicants for CNA Only 17. PhotographsYou are required to submit a passport style photo along with this Application . Acceptable file types are .jpg, .jpeg, and .png. DO NOT SUBMIT PDF VERSIONS OF YOUR PHOTO. _____ Section VII. To be completed by ALL APPLICANTS 6 18. Signature (See below Disclosure)0F1_____ _____ Signature Date i An Application for Med Tech renewal will NOT be processed without the clinical update submitted by the instructor. ii Your RN Instructor Must Submit a Class List with your Med Tech Renewal Application iii You are considered an applicant for CNA endorsement if you hold a CNA cert in another state iv You are required to provide copies of your certificate for each state listed in this section v You are considered an initial applicant if you have never held a CNA certification in Maryland or any other state 1 The parties agree that this agreement may be electronically signed.