Certified Medication Aide Enrollment Questionnaire | American Safety Programs and Training

Thank you for your interest in the Certifed Medication Aide Course with American Safety Programs in partnership with the University of Rhode Island.

Below you will find a questionnaire. These are the requirements for the course. Should you not meet a requirement you will be refunded for any payments you have made to American Safety Progrmas.

Once you have completed this form you will be given a form for your Director of Nurses or Administrator stating that they support you taking this course and will allow you to perfrom 3 observed medication passes within 12 months of course completion.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Confirm Email

Phone *

High school Diploma or GED *

Licensed Active CNA and at least 18 years old *

CNA Facility Requirement *

You must be employed by one of the following.

Med Pass Requirement *

You must complete 3 observed Medication Passes in your facility

Citizen/Non Citizen Status *

Required to attend every class (45 hours) *

Signature *

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