DODD MA Certification Course Application

DODD

Application for Personnel to Attend the DODD Medication Administration (MA) Certification Course

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1SECTION 1: To Be Completed by EMPLOYER

2SECTION 2: To Be Completed by DD PERSONNEL

⚠️ Before You Begin

To attend a DODD Medication Administration Certification course (Initial or Renewal), this application must be fully completed — including all required Employer and DD Personnel information and signatures — before the class date.

Applications that are incomplete or missing required signatures are not eligible for DODD Medication Administration certification.
Both the Employer and DD Personnel sections must be submitted in full.

🔔 Reminder: Completing this application does not reserve a seat. You must be registered for a course on the Clearwater COG Calendar in addition to completing this application.

Registering multiple students?
A separate application is required for each student attending training. If you registered multiple students during course registration, please complete and submit this application once for each student.

SECTION 1: The following fields must be fully completed by the employer.

DD Personnel Name *

First

Last

Date of Application *

Are you? *

Agency Employer
DODD Certified Independent Provider

Employer *

If you are a DODD Certified Independent Provider, for purposes of this application, you are the employer.

DODD Provider Number *

Work location address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone Number *

Work location start date *

Name of supervisor of DD personnel *

Title of supervisor of DD personnel *

Email of supervisor of DD personnel *

Phone of supervisor of DD personnel *

Date supervisor began supervision of DD personnel *

Please verify all of the following are true as of the date of the application:

This person is employed by the agency. *

Yes
No
NA - this person is an independent provider

Employment Start Date:

This person is at least 18 years of age. *

The agency has been provided documented proof of this person’s high school diploma or GED. *

Yes
No
NA - this person is an independent provider and will submit proof of diploma with this application

All background check requirements have been completed according to OAC 5123-2-02 including results and registry checks within the specified time frames. *

Yes
No
Yes - this person is an independent provider

Date this applicant started employment at listed agency, if an Independent Provider, enter N/A: *

As the agency employer of the DD personnel whose name appears on this application, I attest that all information provided on this application is accurate and current. *

First

Last

Title of agency employer or designee *

Signature of agency employer or designee *

Clear Signature

Please sign above using your mouse, trackpad, or touchscreen.

Date *

📩 Employer: Complete Your Section First

Before continuing:

✅ Complete all Employer fields.
✍️ You have signed the application above.
📧 Click Save and Resume Later below to generate a secure link for your DD Personnel.
🔗 Email the link to your DD Personnel so they can complete Section 2.

⚠️ Do not send the link until the Employer section is complete and signed.

Reminder: Completing this application does not reserve a seat. You must also register for a course through the Clearwater COG Calendar.

Save and Resume Later

SECTION 2: The following fields must be completed by DD personnel.

Prior to attending a DODD MA Certification Course: DD Personnel are required to complete this application, including all information and signatures. Without a completed application DD Personnel will not be eligible for DODD Medication Administration certification to administer medications.

This application is for *

(Cat. 1) Medication Administration
(Cat. 1) Renewal
(Cat. 2) G/J Tube Medications
(Cat. 2) Renewal
(Cat. 3) Insulin
(Cat. 3) Renewal

Enter the date of the class you are registering for: *

Have you ever taken a medication administration certification class before this application? *

Name *

First

Middle

Last

Last 4 of SSN *

Date of birth *

Gender *

Male
Female

Are you an independent provider? *

If yes, do you have (must provide proof to RN Trainer) *

High school diploma
High School Equivalency Document

If you are an independent provider, please upload your proof of diploma.

Drag & Drop Files, Choose Files to Upload

Personal street address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Home phone *

Work phone

Cell phone

Email *

At the time of this application, do you work for more than one DD employer? *

**If yes, print the names and provider number of all DD employers you currently work for

DD Employer

DD employer

Provider number

DD Employer

DD employer

Provider number

I attest that all information provided in this application is true, current, and correct. *

Clear Signature

Signature of DD personnel. Please sign above using your mouse, trackpad, or touchscreen.

Date *

✔ Final Review Before Submitting

Before clicking Submit Application, please confirm:

✅ Employer section is complete and signed.
✍️ You have signed the application above.
✔ All information is accurate.

⚠️ Click Submit Application to complete the application.

Do not click Save and Resume Later unless you need to come back and finish this section later.

Reminder: Submitting this application does not reserve a seat. You must also be registered for a course through the Clearwater COG Calendar.

The following portion to be completed by the RN Trainer/Instructor:

RN trainer should keep this application in a retrievable file, which is accessible to authorized personnel and DODD upon request for at least 7 years.

RN trainer signature (Includes validation of HSD/GED for independent providers

Date

Session Number

(if initial certification, not renewal)

Save and Resume Later

Your application has been saved.
A unique link has been generated so a DD personnel can access and complete the remaining portion of the application.

You can either:

Enter your DD personnel’s email address below to automatically send them the link, or
Copy the link and email it to them manually.

⚠️ Important: The application must be completed and submitted electronically before attending the class. This link is private, should not be shared, and will expire in 30 days. After that, the form entry will be permanently deleted.

🔔 Reminder: Completing this application does not reserve a seat. You must be registered for a course on the Clearwater COG Calendar in addition to completing this application.

Registering multiple students? A separate application is required for each student. If you registered multiple students for a course, you may start another application for the next student by visiting the Medication Administration Certification Application.

Copy Link

Email *

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Application for Personnel to Attend the DODD Medication Administration (MA) Certification Course

⚠️ Before You Begin

SECTION 1: The following fields must be fully completed by the employer.

📩 Employer: Complete Your Section First

SECTION 2: The following fields must be completed by DD personnel.

✔ Final Review Before Submitting

The following portion to be completed by the RN Trainer/Instructor:

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