DD Personnel Name
Contact Number (In case class changes due to unforeseen circumstances)
Class Type	☐ 14 Hour Medication Administration and Health Related Activities
☐ 2 hour Recertification Class – Medication Administration and HRA
☐ 4 Hour GT/JT Certification Class
☐ 1 Hour GT/JT Recertification Class
☐ 4 Hour Insulin Certification Class
☐ 1 Hour Insulin Recertification Class
Class Date/Dates
Location	☐ Urbana ☐ Defiance
☐ Troy ☐ Toledo
☐ Lima ☐ Bellefontaine
☐ Columbus
Employer Contact Name
Contact Phone Number
Billing Information Contact
Address
Attendance Roster and Skill Check List to be delivered to: Evidence of Certification can be obtained on the DODD Web Site. The participant will receive a copy of the Certificate form via their own personal e-mail.	☐ Fax #
☐ E-Mail Address:
☐ Address:

This must be accompanied by the DODD Personnel MAIS Application. The DODD Application must be completed and signed by an agency representative attesting to the accuracy of the information.

If you are an independent provider, you must bring evidence of a background check and high school diploma to qualify to become certified.

Return completed forms to fax # 937-653-1321 Attn. DON

Or submit forms electronically to MAregister@crsi-oh.com