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Blank Utah Dopl Ap Form

The Utah DOPL AP form is an essential document for those seeking certification as a Medication Aide in the state of Utah. It serves as a comprehensive application that guides applicants through the necessary steps and requirements for securing their certification, offering detailed instructions on completing the form, submitting the required documentation, and understanding the associated fees. Through its outlined procedures, the form aims to streamline the certification process, ensuring that applicants provide all necessary information to avoid delays or potential denial of their application.

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For individuals seeking to expand their healthcare qualifications in Utah, navigating the process of becoming a certified medication aide requires close attention to the Utah Division of Occupational and Professional Licensing (DOPL) application procedures. The DOPL extends a commitment to providing efficient service, necessitating the submission of a fully completed application alongside requisite documentation and fees to prevent delays or potential denial. Key aspects include a structured application fee, the importance of providing a social security number for identity verification and in compliance with legal mandates for child support enforcement, and the necessity of a comprehensive checklist. This checklist is critical, encompassing requirements from presenting two fingerprint cards for criminal background checks by the Bureau of Criminal Identification (BCI) and the FBI, to documentation verifying completion of an approved training program and current certification in good standing as a Certified Nursing Assistant (CNA) within Utah. Additionally, it highlights the provisional pathway through a temporary certification for those awaiting the opportunity to sit for the MACE Certification Examination. Moreover, the provision for updating personal information, the instructions for submitting name changes, the non-refundable nature of the application fee, and details regarding the exam and renewal of certification encapsulate the multifaceted nature of the application process. This layered procedure ensures that applicants are thoroughly vetted and possess the requisite knowledge and skills, aligning with Utah’s commitment to upholding high standards in the healthcare profession.

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STATE OF UTAH

DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING

MEDICATION AIDE CERTIFIED

MEDICATION AIDE CERTIFIED TEMPORARY

APPLICATION INSTRUCTIONS AND INFORMATION:

General Statement: The Utah Division of Occupational and Professional Licensing (DOPL) desires to provide courteous and timely service to all applicants for licensure. To facilitate the application process, submit a complete application form including all applicable supporting documents and fees. Failure to submit a complete application and supply all necessary information will delay processing and may result in denial. The fees are for processing your application and will not be refunded. Please read

all instructions carefully.

Address of Record: The address provided on this application WILL BE YOUR ADDRESS OF RECORD. All correspondence from DOPL will be sent to that address. You are responsible to directly notify DOPL of any change to your address of record. Do not rely on a forwarding order as state mail is not forwarded.

Social Security Number: A social security number is classified as a private record under the Utah Government Records Access and Management Act. It is used by DOPL as an individual identifier. It is also used for child support enforcement pursuant to Subsection 78-32-17(3) and is mandatory pursuant to Subsection 58-1-301(1), Utah Code Ann., which implements 42 U.S.C. 666(a) (13). If a Social Security Number is not provided, the application is incomplete and may be denied.

APPLICATION INSTRUCTIONS:

Mandatory Attachment Checklist (Applications with incomplete attachments will not be considered and may be denied.)

Submit a complete Division of Occupational Licensing (DOPL) Medication Aide Certified application to the DOPL

address listed below. If you are applying for a temporary certification, you will need to complete the full application. Submit a $90.00 Non-Refundable Application Fee, made payable to “DOPL.” This fee includes a $50.00 application fee

and a $20.00 surcharge for a BCI fingerprint file search, and a $20.00 surcharge for a FBI fingerprint file search.

Submit two applicant fingerprint cards (Form FD-258: white with blue lines) to be used by DOPL for a search through the files of the Bureau of Criminal Identification (BCI) and the Federal Bureau of Investigation (FBI). If you

bring your completed application to DOPL’s office at 160 E 300 S, Main Lobby, Salt Lake City, your fingerprints can be electronically scanned using DOPL’s Identix equipment.

Submit documentation of having completed an approved Medication Aide Certified (MAC) training program. Request

that the training program submit documentation of completion directly to DOPL. Failure to submit official documentation of completion will result in denial of your application as incomplete.

Submit documentation of current certification in good standing as a Certified Nursing Assistant with the Utah Nursing

Assistant Registry.

Submit documentation of a high school diploma or its equivalent.

Submit documentation of a minimum of 2,000 hours of experience as a certified nurse aide in a long-term care facility

within the two years prior to application. Documentation may include W-2 tax forms or a letter from the administrator of a long-term care facility.

Submit two letters of recommendation from a long-term care facility administrator and one licensed nurse familiar with

your work practices as a certified nurse aide.

Submit documentation of successful completion of the MACE Certification Examination

Submit the “Temporary Certification Form”. Please note that the temporary certification will expire if you do not sit for the first available examination or if you fail the examination. Once you have taken the MACE Certification Examination, submit documentation of successful completion to DOPL.

DOPL-AP Rev 2013-09/05

*Important Additional Important Information:

1.Application Processing: Processing time for an application, where the fingerprints have been electronically scanned by DOPL and there are no issues that need to be resolved, is approximately 7 to 21 business days if the application is complete. If the application is incomplete, the processing time will increase.

2.Laws and Rules: You are required to understand Utah laws and rules pertaining to your practice. The following laws and rules are available on the Internet at www.dopl.utah.gov.

Division of Occupational & Professional Licensing Act, 58-1 (Jul 01 2012)

General Rules of the Division of Occupational & Professional Licensing, R156-1 (November 26, 2012)

Nurse Practice Act, 58-31b (Jan 01 2013

Nurse Practice Act Rules, R156-31b (July 08 2010)

3.Education Requirement: You must complete an approved Medication Aide Certified program. Completion of an approved program is documented by submitting an official document from the training program includes the date of completion.

4.Examination Requirement: The required examination will be NCSBN’s Medication Aide Certified Examination (MACE). However, this examination will not be available until February 1, 2014. If you are submitting an application for a temporary certification, please contact the Division after February 1, 2014 for information regarding the MACE examination.

5.Temporary Certification: Temporary Certification may be issued to a person who meets all licensure requirements except the passing of the MACE examination. The temporary certification will be issued for a period of twelve (12) months. Please note: The temporary certification will automatically expire upon release of official examination results if the applicant fails the examination or if the applicant does not take the first available examination.

6.Certification Renewal: All medication aide certified certification expire March 31 of each odd-numbered year. Each licensee is responsible to renew the license PRIOR to the expiration date shown on the current certification. Approximately two months prior to the expiration date shown on the license, renewal information is disseminated to each licensee’s address of record, as provided to DOPL. Under Utah’s renewal system, all licenses in each profession expire as a group on the same day every two years. Therefore, the length of a licensee’s first renewal cycle depends on how far into the current renewal cycle initial licensure was obtained. Each renewal cycle thereafter is for a full two years. Additionally, the fee paid with this application for licensure is an application-processing fee only.

7.Updating Address Information: It is your responsibility to maintain a current address with DOPL. If your address is incorrect, you will not receive correspondence from DOPL. Address changes can be made online at www.dopl.utah.gov.

Please note that the Division of Occupational and Professional Licensing, section 58-1-301.7(1) Change of information reads:

(a)An applicant, licensee, or certificate holder shall send the division a signed statement, in a form required by the division, notifying within 10 business days of a change in mailing address.

(c)In addition to providing a mailing address, an applicant, licensee, or certificate holder may provide to the division, in a form required by the division, an email address and may designate email as the preferred method of receiving notifications from the division.

7.Name Change: If you have been licensed or certified by DOPL under any other name, please submit documentation of your name change (i.e. copy of a marriage license or divorce decree).

8.Fingerprint Information: All applicants are required to undergo a criminal background check and fingerprint search through the files of the bureau of Criminal Identification (BCI) and the Federal Bureau of Investigation (FBI). To expedite the licensure process, you can obtain electronic fingerprinting at DOPL’s office at 160 E. 300 S., Salt Lake City, 8:00 a.m. to 4:30 p.m., Monday through Friday, except holidays. The cost for having fingerprints electronically scanned by DOPL is covered in the $40 non-refundable surcharge fee. Applicants that arrive late in the day without leaving sufficient time to be processed will be turned away. A current government issued picture ID is required and would include one of the following: a driver’s license issued by Washington D.C., a state of the United States of America or an identification card issued by the state of Utah.

DOPL-AP Rev 2013-09/05

If you are unable to obtain electronic fingerprints at DOPL’s office, you must include two (2) blue fingerprint cards (Form FD-258) with your application for each individual associated with the application as defined above. To have your fingerprints rolled onto the blue fingerprint cards, you must go to BCI, a local police station or an agency authorized by the FBI to roll fingerprints. If you downloaded the application from the Internet, you may obtain fingerprint cards the Bureau of Criminal Identification (BCI), your local police station or authorized agency. Fingerprint cards that are not complete and/or properly rolled will be rejected, delaying the licensure process. Due to the high number of inked fingerprint cards that are rejected and the amount of time it takes state and federal government agencies to process these cards, applicants are encouraged at the time of application to have their fingerprints electronically scanned at DOPL or at the Bureau of Criminal Identification.

Bureau of Criminal Identification (BCI) Information:

Check with BCI for pricing of their services

Walk-ins only; no appointments taken

Fingerprinting and Photo Services are available from 8:00 a.m. – 5:00 p.m., Monday - Friday except holidays

Government-issued picture ID required (driver’s license, state ID, passport, etc.)

Address: 3888 W. 5400 S., Taylorsville, UT 84118 (1/2 block west of Bangerter Highway, behind McDonalds)

Website: www.bci.utah.gov. Telephone number: (801) 965-4569

Review of your FBI Record: If you wish to challenge the accuracy of the information in your FBI record, you should contact the agency that contributed the information in question. You may also direct the challenge to the FBI, Criminal Justice Information Services (CJIS) Division, Attn. SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will forward the challenge to the respective agency.

11.Acceptable Forms of Payment: Licensure fees can be paid by check or money order, made payable to “DOPL.” Cash and debit/credit cards (American Express, MasterCard, and Visa) are also accepted in person at DOPL’s main office. Credit card information is not accepted over the telephone.

12. Mail Complete Application to:By U.S. Mail Division of Occupational & Professional Licensing

P.O. Box 146741

Salt Lake City, Utah 84114-6741

By Delivery or Express Mail

Division of Occupational & Professional Licensing

160East 300 South, 1st Floor Lobby Salt Lake City, Utah 84111

Telephone Numbers:

(801) 530-6628

(866) 275-3675 – Toll-free in Utah

DOPL-AP Rev 2013-09/05

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(FOR TWO-SIDED PRINTING)

DOPL-AP Rev 2013-09/05

State of Utah

DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING

160 East 300 South, P.O. Box 146741

Salt Lake City, Utah 84114-6741

Telephone (801) 530-6628

www.dopl.utah.gov

MEDICATION AIDE CERTIFIED MEDICATION AIDE CERTIFIED TEMPORARY

***Please list your full legal name as it appears on your driver’s license, Social Security Card, etc.***

Last Name:			First Name:		Middle Name:

Social Security Number:	-	-		Maiden Name:

I certify under penalty of perjury that:

I am a citizen of the United States and I have a valid US Driver License or US State ID.

License/State ID Number:

State:

I am a citizen of the United States currently living outside the United States and do not have a valid US Drivers License or US State ID. Please attach a legible copy of your valid passport or other documentation to verify you are a legal citizen of the United States.

I am a non-citizen of the United States, who is lawfully present in the United States and I have a valid US Drivers License or US State ID.

License/State ID Number:State:

I am a non-citizen of the United States, who is lawfully present in the United States and I do not have a valid US Drivers License or US State ID. Please attach a legible copy of your current and valid government issued document showing evidence of authorization to work in the United States.

I am a foreign national not physically present in the United States.

Mailing Address:

City:				State:	ZIP:

Male	Date of Birth:	Phone #:	E-Mail:
Female	Date of Birth:	Phone #:	E-Mail:
Female

DO NOT WRITE IN THIS SECTION - FOR DIVISION USE ONLY
License/Certificate/Exam approval Number:
Date License/Certificate/Exam approval - Approved: ___/___/____
Approved By:
Date License/Certificate/Exam approval Denied: ___/___/____
Denied By:
Reason for Denial/Other Comments:

DOPL-AP Rev 2013-09/05

List all licenses, registrations, or certifications issued by any state which you now hold or have ever held in any profession. (Use

additional sheets if necessary.)

Profession:	Issuing State:

License/Certification Number:	License/Certification Status:	Issue Date:

Profession:	Issuing State:
License/Certification Number:	License/Certification Status:	Issue Date:

I do not hold registrations, or certifications issued by any jurisdiction.

Approved Medication Aide Certified Training Program:

(Course must be at least 60 clock hours of classroom learning and 40 clock hours of clinical practice.)

Name of Training Program:

Address of Program:

City:		State:	Zip:

Dates Attended:	From:	To:

High School Education Requirement:

	Name of School:
	City:	State:		Zip:
	Date of Graduation:
OR:	Equivalent Education:		Date Earned:

Medication Aide Certified Examination Requirement:

Date Taken:

Number:

Expiration:

AFFIDAVIT and RELEASE AUTHORIZATION

I am the applicant described and identified in this application for licensure, certification, or registration in the State of Utah.

I am qualified in all respects for the license, certificate, or registration for which I am applying in this application.

To the best of my knowledge, the information contained in the application and its supporting document(s) is free of fraud, misrepresentation, or omission of material fact.

To the best of my knowledge, the information contained in the application and its supporting document(s) is truthful, correct, and complete; and, discloses all material facts regarding the applicant and associated individuals necessary to properly evaluate the applicant’s qualifications for licensure.

I will ensure that any information subsequently submitted to the Division of Occupational and Professional Licensing in conjunction with this application or its supporting documents meet the same standard as set forth above.

I understand that it is unlawful and punishable as a class A misdemeanor to apply for or obtain a license or to otherwise deal with the Division of Occupational and Professional Licensing or a licensing board through the use of fraud, forgery, or intentional deception, misrepresentation, misstatement, or omission.

I understand that this application will be classified as a public record and will be available for inspection by the public, except with regard to the release of information which is classified as controlled, private, or protected under the Government Records Access and Management Act or restricted by other law.

I authorize all persons, institutions, organizations, schools, governmental agencies, employers, references, or any others not specifically included in the preceding characterization, which are set forth directly or by reference in this application, to release to the Division of Occupational and Professional Licensing, State of Utah, any files, records, or information of any type reasonably required for the Division of Occupational and Professional Licensing to properly evaluate my qualifications for examination approval/licensure/certification/registration by the State of Utah.

Signature of Responsible Party:

Date of Signature: ____/____/____

Printed Name of Responsible Party:

COMPLIANCE WITH UTAH LAWS AND RULES

I understand that it my continuing responsibility to read, understand, and apply the requirements contained in all statutes and rules pertaining to the occupation or profession for which I am applying, and that failure to do so may result in civil, administrative, or criminal sanctions.

Name: ____________________________________ Signature: ____________________________________ Date: __________

DOPL-AP Rev 2013-09/05

			MEDICATION AIDE CERTIFIED QUALIFYING QUESTIONNAIRE
			Read thoroughly, and answer the questions. Do not leave any question blank.
		(Note: If you have formally expunged a criminal record you do not need to disclose that criminal history.)

Yes	No	1.	Have you ever applied for or received a license, certificate, permit, or registration to practice in a regulated
Yes	No		profession under any name other than the name listed on this application?


Yes	No	2.	Have you ever been denied the right to sit for a licensure examination?

Yes	No	3.	Have you ever had a license, certificate, permit, or registration to practice a regulated profession denied,
Yes	No		conditioned, curtailed, limited, restricted, suspended, revoked, reprimanded, or disciplined in any way?

		4.	Have you ever been permitted to resign or surrender a license, certificate, permit, or registration to practice in a
Yes	No		regulated profession while under investigation or while action was pending by any health care profession licensing
			agency, hospital or other health care facility, or criminal or administrative jurisdiction?
Yes	No	5.	Are you currently under investigation or is any disciplinary action pending against you now by any licensing
Yes	No		agency or governmental agency?
			agency or governmental agency?
Yes	No	6.	Have you ever had hospital or other health care facility privileges denied, conditioned, curtailed, limited, restricted,
Yes	No		suspended, or revoked in any way?
			suspended, or revoked in any way?
		7.	Have you ever been permitted to resign or surrender hospital or other health care facility privileges, while under
Yes	No		investigation or while action was pending by any licensing agency, hospital or other health care facility, or criminal
			or administrative jurisdiction?
Yes	No	8.	Is any action related to your conduct or patient care pending at any hospital or health care facility?
Yes	No

Yes	No	9.	Have you ever had rights to participate in Medicaid, Medicare, or any other state or federal health care payment
Yes	No		reimbursement program denied, conditioned, curtailed, limited, restricted, suspended, or revoked in any way?

		10.	Have you ever been permitted to resign from Medicaid, Medicare, or any other state or federal health care payment
Yes	No		reimbursement program while under investigation or while action was pending by any licensing agency, hospital,
			or other health care facility, or criminal or administrative jurisdiction?
Yes	No	11.	Is any action pending against you now by Medicaid, Medicare, or any other state or federal health care payment
Yes	No		reimbursement program?
			reimbursement program?
		12.	Have you ever had a federal or state registration to sell, possess, prescribe, dispense, or administer controlled
Yes	No		substances denied, conditioned, curtailed, limited, restricted, suspended or revoked in any way by either the federal
			Drug Enforcement Administration or any state drug enforcement agency?
		13.	Have you ever been permitted to surrender a registration to sell, possess, prescribe, dispense, or administer
Yes	No		controlled substances while under investigation or while action was pending by any health care profession
			licensing agency, hospital or other health care facility, or criminal or administrative jurisdiction?
Yes	No	14.	Is any action now pending against you by either the Federal Drug Enforcement Administration or any state drug
Yes	No		enforcement agency?
			enforcement agency?
Yes	No	15.	Have you been named as a defendant in a malpractice suit?

Yes	No	16.	Have you ever had office monitoring, practice curtailments, individual surcharge assessments based upon specific
Yes	No		claims history, or other limitations, restrictions, or conditions imposed by any malpractice carrier?

Yes	No	17.	Have you ever had any malpractice insurance coverage denied, conditioned, curtailed, limited, suspended, or
Yes	No		revoked in any way?
			revoked in any way?
		18.	If you are licensed in the occupation/profession for which you are applying, would you pose a direct threat to
Yes	No		yourself, to your patients or clients, or to the public health, safety, or welfare because of any circumstance or
			condition?
Yes	No	19.	Have you ever been declared by any court of competent jurisdiction incompetent by reason of mental defect or
Yes	No		disease and not restored?
			disease and not restored?

Yes	No	20.	Have you ever been terminated from a position because of drug use or abuse?
		21.	Are you currently using or have you recently (within 90 days) used any drugs (including recreational drugs)
Yes	No		without a valid prescription, the possession or distribution of which is unlawful under the Utah Controlled
			Substances Act or other applicable state or federal law?
		22.	Have you ever used any drugs without a valid prescription, the possession or distribution of which is unlawful
Yes	No		under the Utah Controlled Substances Act or other applicable state or federal law, for which he has not
Yes	No		successfully completed or is not now participating in a supervised drug rehabilitation program, or for which he has

			not otherwise been successfully rehabilitated?
Yes	No	23.	Have you ever had a documented case in which he was involved as the abuser in any incident of verbal, physical,
Yes	No		mental, or sexual abuse?
			mental, or sexual abuse?
Yes	No	24.	Do you currently have any criminal action pending?
Yes	No	25.	Have you ever pled guilty to, no contest to, or been convicted of a felony in any jurisdiction?
DOPL-AP Rev 2013-09/05				7

Yes	No	26.	Have you ever been incarcerated for any reason in any federal, state or county correctional facility or in any
Yes	No		correctional facility in any other jurisdiction or on probation/parole in any jurisdiction?

		27.	Have you ever pled guilty to, no contest to, entered into a plea in abeyance or been convicted of a misdemeanor in
Yes	No		any jurisdiction? Motor vehicle offenses such as driving while impaired or intoxicated must be disclosed but
			minor traffic offenses such as parking or speeding violations need not be listed.
Yes	No	28.	Have you been allowed to plea guilty or no contest to any criminal charge that was later dismissed (i.e. plea-in-
Yes	No		abeyance or deferred sentence)?
			abeyance or deferred sentence)?

If you answered “yes” to questions 24, 25, 26, 27 or 28 above, you must submit a complete narrative of the circumstances that occurred for EACH and EVERY conviction, plea in abeyance, and/or deferred sentence. You must also attach copies of all applicable police report(s), court record(s), and probation/parole officer report(s).

If you are unable to obtain any of the records required above, you must submit documentation on official letterhead from the police department and/or court indicating that the information is no longer available.

If you have formally expunged a criminal record as evidenced by a court order signed by a judge, you do not need to disclose that criminal history. Expungement orders must be sent to the Bureau of Criminal Identification and the FBI to enable the expungement to be completed and the criminal history eliminated from the records.

If you answered “yes” to any of the above questions, enclose with this application complete information with respect to all circumstances and the final result, if such has been reached.

A “yes” answer does not necessarily mean you will not be granted a license; however, DOPL may request additional documentation if the information submitted is insufficient.

DOPL-AP Rev 2013-09/05

Utah Division of Occupational and Professional Licensing 160 East 300 South, P.O. Box 146741

Salt Lake City, Utah 84114-6741 FAX: (801) 530-6511

MEDICATION AIDE CERTIFIED

TEMPORARY CERTIFICATION

REQUEST FORM

TO BE COMPLETED BY APPLICANT:

Name:			Telephone:

Address:
City:	State:	Zip:		Email:

Date Taking MACE Examination:

Employing Facility:			Telephone:
Address:
City:	State:	Zip:		Email:

Date Employment Begins:

I hereby certify that I will not practice as a medication aide certified until I have been granted a temporary license. Once the temporary license has been issued, I will only practice under direct supervision of a license nurse as defined in the Nurse Practice Act Rule R156-31b-102(41).


Signature of Applicant:	Date:

TO BE COMPLETED BY SUPERVISING NURSE:

Name:

Address:				Telephone:
City:	State:		Zip:		Email:
Position or Title:		License Number:

I hereby certify that I am a licensed nurse in good standing and I will supervise the practice of the above named Medication Aide Certified. I understand that I must provide direct supervision, and be on the same site as the applicant. The Nurse Practice Act Rule subsection R156-31b-102 reads:

(41) "Supervision", as used in this rule, means the provision of guidance and review by a licensed nurse for the accomplishment of a nursing task or activity, including the provision for the initial direction of the task, periodic inspection of the actual act of accomplishing the task or activity, and evaluation of the outcome.

Signature of Supervisor:	Date:

DOPL-AP Rev 2013-09/05

⇓ Utah Dopl Ap PDF

Form Breakdown

Fact Name	Description
Governing Laws and Rules	The application for Medication Aide Certified is subject to Utah laws including the Division of Occupational & Professional Licensing Act, General Rules of the Division of Occupational and Professional Licensing, and the Nurse Practice Act and its rules. These ensure that applicants meet the required legal and professional standards.
Application Fee	The application for certification requires a non-refundable fee of $90, which includes the application fee, and surcharges for both BCI and FBI fingerprint file searches. This fee supports the processing of the application within the Division of Occupational and Professional Licensing.
Required Documentation	Applicants must submit several documents including a completed application form, two fingerprint cards for background checks, proof of completed Medication Aide Certified training, current certification as a Certified Nursing Assistant, a high school diploma (or equivalent), documentation of relevant experience, and letters of recommendation.
Educational Requirement	To apply for a Medication Aide Certified certification, one must complete an approved training program. Documentation of completion, including the date, must be submitted directly to DOPL by the training program to ensure the applicant's eligibility for licensure.
Temporary Certification	Temporary certification may be issued to applicants who meet all other requirements but have yet to pass the MACE examination. The temporary certification is valid for 12 months but expires automatically if the applicant fails the MACE examination or does not take the first available exam following their application.

Detailed Steps for Writing Utah Dopl Ap

Preparing and submitting the Utah DOPL AP form for Medication Aide Certified or Temporary status is crucial for those seeking licensure in this field. This process, detailed below, involves a series of steps aimed at documenting your qualifications and background to ensure eligibility and compliance with state regulations. Proper completion and submission of this form, along with the required attachments and fees, initiate the process towards obtaining your certification. It is imperative to adhere to the guidelines provided to avoid delays or denial of your application.

Begin by obtaining the Medication Aide Certified application from the Utah Division of Occupational and Professional Licensing (DOPL).
Ensure to fill out the application form completely, including your full legal name as it appears on your driver’s license or Social Security card.
Provide a social security number; remember, this is essential for processing your application.
Include your current mailing address under the Address of Record section. This address will be used for all official correspondence related to your licensure.
Attach the mandatory non-refundable application fee of $90.00, payable to “DOPL.” This includes application and fingerprint file search surcharges.
Provide two fingerprint cards (Form FD-258) for the BCI and FBI searches, or opt for electronic scanning at DOPL’s office, if possible.
Submit official documentation of successful completion of an approved Medication Aide Certified (MAC) training program. This must be sent directly to DOPL from the training program.
Include proof of current certification in good standing as a Certified Nursing Assistant with the Utah Nursing Assistant Registry.
Attach evidence of a high school diploma or its equivalent.
Present documentation verifying a minimum of 2,000 hours of experience as a certified nurse aide in a long-term care facility within two years prior to applying.
Submit two letters of recommendation from a long-term care facility administrator and one licensed nurse familiar with your work.
If applicable, provide documentation of having passed the MACE Certification Examination or the “Temporary Certification Form." If opting for temporary certification, remember it expires once examination results are released or if not taken at the first opportunity.
Mail the completed application and all required supporting documents to the appropriate DOPL address, depending on your method of delivery.

Upon successful submission, your application will undergo a processing period, typically spanning 7 to 21 business days, provided there are no issues or incomplete information. It’s important to understand Utah’s laws and regulations pertaining to your practice, as compliance is crucial for licensure. Remember, maintaining updated contact information with DOPL is your responsibility to ensure you receive all necessary correspondence regarding your licensure status.

Common Questions

What is the Utah DOPL AP form?

The Utah DOPL AP form is an application used by individuals seeking licensure as Medication Aide Certified or Medication Aide Certified Temporary by the Utah Division of Occupational and Professional Licensing (DOPL). This form is necessary for processing and verifying the eligibility of candidates for certification.
Who needs to submit the Utah DOPL AP form?

Individuals seeking to become certified as a Medication Aide in Utah must submit the Utah DOPL AP form. This includes those applying for both permanent and temporary certification.
What are the components of a complete application?

A complete application includes the DOPL Medication Aide Certified application, a $90.00 non-refundable fee, two fingerprint cards for background checks, proof of completing an approved Medication Aide Certified (MAC) training program, documentation of current certification as a Certified Nursing Assistant in Utah, a high school diploma or equivalent, documentation of 2,000 hours of experience in a long-term care facility, two letters of recommendation, and documentation of passing the MACE Certification Examination or a Temporary Certification Form.
Can the application fee be refunded?

No, the $90.00 application fee is for processing the application and cannot be refunded, regardless of the application's outcome.
How can an applicant change their address of record with DOPL?

Applicants are responsible for directly notifying DOPL of any change to their address of record. Address changes can be made online at the DOPL website. A forwarding order is not sufficient as state mail is not forwarded.
What is the importance of the applicant's Social Security Number?

The Social Security Number is used by DOPL as an identifier and is mandatory for application. It's also used for child support enforcement. Without it, the application is considered incomplete and may be denied.
What happens if the application is incomplete?

An incomplete application will delay processing, increase processing time, and may result in the denial of licensure.
What are the requirements for the fingerprint process?

Applicants must submit two fingerprint cards for a background check or have their fingerprints electronically scanned at DOPL’s office. Incomplete or improperly rolled fingerprints cards may be rejected, delaying the licensure process.
How does one renew their Medication Aide Certified certification?

All medication aide certifications expire on March 31 of each odd-numbered year. Licensees must renew their certification before the expiration date. Renewal information is sent to the licensee's address of record approximately two months before expiration.
What are the steps for applicants with foreign credentials?

Applicants who are not U.S. citizens but are lawfully present in the United States must attach a legible copy of their current and valid government-issued document showing evidence of authorization to work in the United States. Those living outside the U.S. must provide evidence of legal citizenship of the United States, like a valid passport.

Common mistakes

Filling out the Utah DOPL AP form accurately is crucial, but applicants often make mistakes that can delay the process. Understanding these common pitfalls can help ensure a smoother application process.

Not providing a complete application: One of the most common errors is submitting an application without all the necessary information or required attachments. This includes not sending the mandatory $90.00 application fee, failing to provide fingerprint cards, not including documentation of completed Medication Aide Certified training, or forgetting to attach evidence of current certification as a Certified Nursing Assistant.
Incorrect address: Many applicants forget that the address they provide on the application will be their address of record. If this address is not kept current or is inaccurate, important correspondence from DOPL will not reach them, potentially leading to missed updates or renewal information.
Not supplying a Social Security Number: The form specifies that the Social Security Number (SSN) is a mandatory field, used not only as an identifier but also for other statutory reasons. An application without an SSN is considered incomplete and may be denied.
Overlooking the Education and Examination Requirements: Applicants sometimes miss submitting the official documentation proving completion of an approved MAC program or fail to include documentation of having successfully passed the MACE Certification Examination. It's important to remember that both educational and examination requirements must be met for application approval.
Failing to update address information or name changes: Not notifying DOPL of a change in address or a legal name change can lead to serious issues, including not receiving renewal information. Application processing can be significantly delayed if the applicant's current address is not on file or if their legal name does not match other provided documentation.

In conclusion, when applying for Medication Aide Certification in Utah, carefully review all the requirements and ensure every part of the form is completed accurately. Double-check that all attachments are included before submitting the application. By avoiding these common mistakes, applicants can help ensure their applications are processed efficiently and without unnecessary delay.

Documents used along the form

When navigating the process of becoming a Medication Aide Certified (MAC) in Utah, the Utah Division of Occupational and Professional Licensing (DOPL) Application Form is just one piece of the overall process. This vital document is the starting point for your certification journey. However, it's equally important to be aware of additional documents and forms that typically accompany this application to ensure a smooth and successful certification path. Below is a concise overview of these key documents.

FD-258 Applicant Fingerprint Cards: These are essential for the background check conducted through the Bureau of Criminal Identification (BCI) and the Federal Bureau of Investigation (FBI).
Proof of Completion of an Approved Medication Aide Training Program: This document validates that the applicant has successfully completed the necessary training requirements.
Current Certification as a Certified Nursing Assistant: Documentation proving current good standing with the Utah Nursing Assistant Registry is needed.
High School Diploma or Equivalent: A copy of a high school diploma or equivalent certification shows the applicant meets the basic educational prerequisites.
Proof of Working Experience: Documentation such as W-2 tax forms or a letter from a long-term care facility administrator confirming a minimum of 2,000 hours of work as a certified nurse aide.
Letters of Recommendation: These should come from a long-term care facility administrator and a licensed nurse, attesting to the applicant's work practices and competencies.
MACE Certification Examination Results: If applicable, documentation of successful completion of the Medication Aide Certification Examination (MACE).
Temporary Certification Form: For those applying for temporary certification, this form is necessary and holds a place until the MACE Examination is completed.

A successful application not only hinges on the completion and submission of the DOPL Application Form but also on the careful gathering and preparation of the associated documents listed above. Each document plays a crucial role in painting a complete picture of the applicant's qualifications and readiness for certification. By understanding and preparing these documents in advance, applicants can streamline their certification process, ensuring they meet all requirements set forth by the Utah Division of Occupational and Professional Licensing.

Similar forms

The Utah DOPL AP form for Medication Aide Certification shares similarities with various other forms and applications across the realm of professional licensing and certifications. These related documents, while distinct in their specific fields or requirements, often follow a similar structural and procedural framework designed to ensure applicants meet the necessary qualifications and legal standards. A detailed exploration of these documents reveals the common threads woven throughout the fabric of professional certification processes.

The Nursing License Application, used by nurses to obtain licensure to practice within a state, bears resemblance to the Medication Aide Certification form in its requirement for detailed personal information, educational background, and the need for passing a licensing exam. Both applications serve as gateways to careers in the healthcare sector, demanding proof of competence and integrity through various forms of documentation and testing to protect public health and safety.

A Pharmacy Technician License Application also shares commonalities with the DOPL AP form, particularly in its stipulation for background checks and educational prerequisites. These forms not only assess an applicant's qualifications but also their legal standing and ethical fitness to perform tasks that have a direct impact on patient care and medication management, emphasizing the importance of thorough scrutiny in healthcare professions.

The Contractor License Application, used by individuals seeking to legally operate as contractors in construction and related fields, although different in context, mirrors the structure of requiring personal identification, professional experience, and passing of a relevant exam. These measures ensure that only qualified and knowledgeable individuals are authorized to undertake significant responsibilities that affect the safety and well-being of the public.

The Real Estate License Application also parallels the Medication Aide Certification application in its comprehensive evaluation of an applicant’s background, education, and examination performance. Entrusting real estate professionals with major financial and legal transactions necessitates a rigorous vetting process to uphold industry standards and safeguard consumer interests.

The Teacher Certification Application showcases similarities in its dedication to confirming an applicant's educational achievements, moral character, and subject mastery through testing. Both the teaching and medication aide certifications underscore the critical nature of these professions to society’s structure, necessitating a meticulous verification process to ensure the highest standards of service.

The Cosmetology License Application, while catering to a vastly different professional field, aligns with the Medication Aide Certification form in its requirements for educational program completion, practical experience, and passing of a state-sanctioned exam. Such protocols affirm the state’s role in maintaining high industry standards and protecting consumer health and safety across varied sectors.

The Certified Public Accountant (CPA) License Application illustrates similarities in its detailed scrutiny of applicants’ educational credentials, professional ethics, and expertise verified through rigorous examination. Both the CPA and Medication Aide certifications demand high levels of professional knowledge and ethical standards, reflecting their significant societal roles in financial integrity and healthcare, respectively.

The Professional Engineer License Application echoes the DOPL AP form through its emphasis on academic qualifications, practical experience, and examination success. These applications champion the cause of ensuring that only those with the requisite knowledge, skills, and ethical standing enter professions that hold substantial public safety and welfare responsibilities.

Lastly, the Food Handler Permit Application, although less complex, shares the fundamental objective of safeguarding public health through the certification of individuals. It requires applicants to demonstrate knowledge of safe food handling practices, paralleling the Medication Aide’s need to ensure safe medication administration, underscoring a universal commitment to health and safety in public service roles.

These documents, despite catering to diverse professional fields, collectively illustrate the universal principles of qualification, verification, and responsibility embodied in the process of obtaining formal certification or licensure. Each form, including the Utah DOPL AP, plays a pivotal role in upholding professional standards, ensuring only those duly qualified and vetted can enter sensitive roles that directly impact the public.

Dos and Don'ts

When completing the Utah Division of Occupational and Professional Licensing (DOPL) form for Medication Aide Certified or Temporary Medication Aide Certified applications, you should follow certain guidelines to ensure the process goes smoothly. Here’s a combined checklist of dos and don'ts:

Do provide your Social Security Number - It's crucial for the application. Missing this step could result in an incomplete application, leading to potential denial.
Don't forget the application fee - A $90.00 non-refundable fee is required. Ensure your payment method is acceptable (check, money order, or in person for cash and card payments).
Do include all necessary documentation - From fingerprint cards to proof of completed training and work experience. Each piece of documentation is a key part of your application.
Don't submit incomplete forms - Incomplete applications will not be considered. Double-check that every field is filled in and that you’ve followed all instructions precisely.
Do ensure your address is current - This address will be your official address of record for correspondence from DOPL.
Don't rely on mail forwarding - State mail will not be forwarded. It's your responsibility to directly inform DOPL of any address changes.
Do keep a copy of your entire application for your records - Before submitting, make a copy of the completed application and all accompanying documents for your personal records.
Don't wait until the last minute to submit your application - Processing times can vary, and waiting until close to your desired start date could result in delays that impact your plans.

By carefully following these recommendations, you can help ensure a smoother application process, avoid unnecessary delays, and increase your chances of a successful submission to the Utah DOPL.

Misconceptions

Understanding the Utah Division of Occupational and Professional Licensing (DOPL) application form for Medication Aide Certified (MAC) and Medication Aide Certified Temporary can sometimes lead to misconceptions. Below are four common misunderstands and explanations to clarify these aspects.

Misconception 1: The application fee is refundable if my application is denied or I decide not to complete my certification. Many applicants believe that if they change their minds about becoming certified or if their application is denied, they will receive a refund of their application fee. However, the instructions clearly state that the fees for processing the application are non-refundable regardless of the application's outcome.
Misconception 2: Once I submit my application, the processing time is guaranteed. The document indicates that the processing time for an application can be approximately 7 to 21 business days, assuming there are no issues and fingerprints have been electronically scanned. However, this is not a guaranteed timeframe. Incomplete applications or ones requiring additional information will experience delays.
Misconception 3: Electronic fingerprinting is optional for all applicants. While you may submit two fingerprint cards with your application, electronic fingerprinting at DOPL’s office is highly encouraged to expedite the licensure process. Incomplete or improperly rolled ink fingerprint cards can significantly delay the application process. Hence, electronic fingerprinting is not just an option but a strongly advised step.
Misconception 4: Temporary certification is automatically extended if I fail the MACE examination. Some applicants mistakenly believe that if they do not pass the MACE examination, their temporary certification will be extended or automatically renewed. However, the temporary certification explicitly expires if the applicant fails the examination or does not take the first available examination. It must be noted that passing the examination is a requisite for maintaining certification.

Understanding these key elements of the Utah DOPL AP form is essential for a smooth and successful application process. Applicants should carefully review all instructions and ensure that their application is complete before submission to avoid any delays or misunderstandings.

Key takeaways

Filling out and using the Utah DOPL Application for Medication Aide Certified positions involves several important steps and requirements. Understanding these can simplify the process and ensure that applicants submit their applications properly. Here are six key takeaways:

Complete Application and Mandatory Attachments: It's crucial to submit a fully completed application along with all the necessary supporting documents and appropriate fees. Incomplete applications or missing information can significantly delay the process and may even result in application denial.
Address of Record: The address provided on the application becomes the official address of record. All communications from the Division of Occupational and Professional Licensing (DOPL) will be sent to this address. Applicants must notify DOPL directly of any changes to this address to ensure they receive all correspondence promptly.
Requirement of Social Security Number: The application requires a Social Security Number (SSN) due to its role as an individual identifier and its use in child support enforcement and other mandatory checks under Utah law. Lack of an SSN on the application renders it incomplete and may lead to its denial.
Background Checks: Fingerprinting for a criminal background check through the Bureau of Criminal Identification (BCI) and the Federal Bureau of Investigation (FBI) is a mandate. Applicants can have their fingerprints electronically scanned at DOPL’s office for a faster and more reliable submission process, which includes a non-refundable surcharge fee.
Temporary Certification: Applicants meeting all other licensure requirements except for passing the Medication Aide Certified Examination (MACE) may be eligible for temporary certification. This certification is valid for twelve months, expiring automatically if the applicant fails or does not sit for the first available examination.
Certification Renewal: Medication aide certified certifications expire on March 31 of every odd-numbered year. It's the responsibility of each licensee to renew their license before the expiration date. Failing to renew on time can result in a lapse of certification and the ability to legally work in the certified capacity.

Understanding these requirements and preparing accordingly can make the application process for Medication Aide Certified positions in Utah more streamlined and less stressful.

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