Submit New Application

NEW TEST OBSERVER APPLICATION (allows you to administer both the Knowledge and Skills portions of the exams) Application

Please fill out this application and attach the following documentation:
  • 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 eighty-nine dollars and ninety-five cents ($89.95) 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.

You will attest in the Affidavit at the end of this document that you have read, understand, and will abide by the following documents. 
Click to open: ACTOR TRAINING GUIDELINES
Click to open: KNOWLEDGE TEST PROCTOR (KTP) GUIDELINES
Click to open: TEST SITE EQUIPMENT LIST (1503SD)

Once you have completed all the fields and uploaded the required documents within this application, 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
RN License Information
WORK EXPERIENCE VERIFICATION
TEST SITE INFORMATION
RESUME
Affidavit
CONFIDENTIALITY/NONDISCLOSURE:
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.
  •  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 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 nurse aide competency examination by calling the D&SDT-HEADMASTER home office at (800)393-8664.

ACTOR AND KNOWLEDGE TEST PROCTOR (KTP) TRAINING AFFIDAVIT:
As a certified Test Observer, I swear that I have provided and reviewed and will abide by the Actor and Knowledge Test Proctor training guidelines with any individual(s) I choose to use as an Actor or Knowledge Test Proctor.   Click the following links to open the Actor Training Guidelines and KTP Training Guidelines.
  • I attest that the individual(s) I choose to use as my Actor and/or KTP have completed the Actor and/or Knowledge Test Proctor (KTP) Training Affidavit and Confidentiality/Nondisclosure Agreement Applications available at https://sd.tmutest.com/apply
  • I also understand that any Actor or Knowledge Test Proctor I choose to use will not be able to sit for the Nurse Aide test for six (6) months from the date that I last used them as an Actor or Knowledge Test Proctor.
TEST SITE EQUIPMENT LIST: Click here to open the 1503SD Test Site Equipment List 
I hereby certify that the test sites where I test will be checked before starting each test event to ensure that the test site equipment listed on the 1503SD Form is available and in good working order. If not, I will report missing or inoperable test site equipment by listing it in TMU© under the test irregularities before submitting my test event observations for scoring.

As a CERTIFIED TEST OBSERVER,  I will administer tests as a regular part of my duties with no compensation from HEADMASTER or SDHCA. I am working as a Certified Test Observer for the organization listed below. Certified Nurse Aide Candidates tested and/or any volunteer test subjects used will be employees and/or under contract of our organization and therefore covered by our organization’s liability policy.
 
As a Certified Test Observer for this organization, I understand that I have the option to test candidates who are not employed by our organization. I will administer these tests as a regular part of my duties with no compensation from HEADMASTER or SDHCA.  Furthermore, candidates not employed and/or under contract by our organization that I agree to test will be covered by our organization’s liability policy.
  • I understand that there is a  one-time fee of one hundred dollars ($100.00) 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 $89.95
Non-Refundable. All fees are non-refundable.
1-800-952-3052