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Resident Actor Training Affidavit and Confidentiality/Nondisclosure Agreement Application

BECOMING A RESIDENT ACTOR: 
To become a resident actor, you must review and be trained with the Actor Training Guidelines by a certified Test Observer.  You must also meet the criteria listed below. After accomplishing these tasks, you may then be used as a resident actor. 

To qualify as a resident actor, you must meet the following criteria:  
  • Resident actors need to understand that they cannot sit for the State NA competency test for six months (6 months) from the date they last worked as a resident actor. 
  • Resident actors must be of legal working age in the South Dakota they are working. Minors must also have a work permit where required by State law. 
  • Resident actors must be trained and certified with the approved Actor Training Guidelines. 
  • Resident actors may NOT be Nurse Aide Test Candidates who have not been tested. 
  • Resident actors may NOT be students in any NA Training Program. 
  • Resident actors can be registry active NAs, testing team family members, volunteers, etc. 
Once you have completed all the fields within this document, select 'Send Application' to submit your application.

If you have any questions, please contact the South Dakota Health Care Association (SDHCA) office via email at luannseverson@sdhca.org or call the SDHCA office at (800) 952-3052.
Address
Test Observer Name
Affidavit
As a nurse aide skill test Resident Actor, I swear that I have reviewed the Actor Training Guidelines with the Test Observer named, and I understand and will abide by the approved material presented.  Click to open:  Link to Actor Training Guidelines.
  • I understand that as a resident actor, I will not be permitted to apply and take the South Dakota Nurse Aide exam for six months from the date that I last worked as a resident actor.
CONFIDENTIALITY/NONDISCLOSURE AGREEMENT:
I acknowledge the confidential nature of the nursing assistant competency examination. This includes the materials, processes, procedures, and content of the examination's knowledge and manual skills portions.
  •  I agree to safeguard the confidentiality of all information about the nursing assistant 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, nor will I disclose any test content, examination results, or information about any Nurse Aide candidate's performance with instructors or administrators of any training facility, program, or with anyone else other than the  Test Observer, D&SDT-HEADMASTER staff, or the appropriate State agency.  
  • I will not be involved in testing family members or close personal friends, except in emergency situations as provided for in the D&SDT-HEADMASTER and State Guidelines.
TEST SECURITY: 
I will maintain and never violate the security of the tests or compromise any testing information. I understand that if I violate test security, I will be held legally accountable and prosecuted to the full extent of the law.
By Submitting
I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.
1-800-952-3052