New Jersey Department of Health

Assisted Living Program

APPLICATION FOR APPROVAL OF A CERTIFIED MEDICATION AIDE TRAINING

AND COMPETENCY EVALUATION PROGRAM (MATCEP) IN ASSISTED LIVING RESIDENCES/

ASSISTED LIVING PROGRAMS/COMPREHENSIVE PERSONAL CARE HOMES

ADDENDUM: CMA TRAINING - LIST OF COURSE ATTENDEES

INSTRUCTIONS: Please PRINT legibly. This form must accompany the Application for Approval (NA-4) form. It is the School Official’s responsibility to verify by checking the registry that each candidate listed below is currently certified in New Jersey using the Online Public Registry at http://njna.psiexams.com/ or http://www.njconsumeraffairs.gov/LVinfo.htm.

School Name

Class Start Date (mm/dd/yyyy)

Name of County

Name of Certified Aide	Date Verified	Certificate Type*	NJ Certification Number	Expiration Date
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* HHHA-Homemaker/Home Health Aide NA-Nurse Aide PCA-Personal Care Assistant

As the School Official, I certify that I have verified by checking the registry that each candidate listed above is currently certified in New Jersey.
Name (Print) of School Official

Contact Number

Signature of School Official	Date

NA-11

OCT 13

NA-11, Addendum of Course Attendees

NA-11, Addendum, NA-4, course, attendees, MATCEP

Elaine White

2008-07-31

ewhite

NJDOH