Instructions for Completing Scantron Registration Form

Read the instructions below before you begin filling out your registration form.

General Information

Exam Fees
Type of Exam Testing Fee Pre-Registration
Required
Medication Aide $25.00 Yes
Administrator $50.00 Yes
Alternative No charge Yes

Payment must be in the form of a money order or certified check made payable to "DHSR." Personal or company checks are not accepted. Improper forms of payment will delay in registering for your test site. Fees are non-refundable and non-transferable once submitted to DHSR. Payment will not be accepted at testing locations. Medication aide and administrator registration forms must be mailed with appropriate testing fee.

Instructions for Items 1 through 17

  1. Name Field **
    • Print your last name in the name blocks beginning with the far left block. Write one letter in each block. If there are blocks left over after you write in your last name, leave them blank.
    • Then, starting with first letter of your last name, find the circle in the column below that matches the first letter of your last name and fill in that circle. Repeat this step for each letter in your last name. In each column, fill in the circle with the letter that matches the letter in the above block.
    • After you have filled in the circles that match the letter in your last name, repeat the steps above for your first name (no nick names, use the same name on your driver's license) and middle initial.
  2. Social Security Number **
    • Starting with the block at the far left, enter your Social Security number.
    • In the column below each number you entered, fill in the circle that matches the number in the above block.

      (The Social Security number is used for identification purposes only to verify whether a person has passed and/or registered for the exam.)

  3. Birth Date **
    • Fill in the circle that matches the month you were born.
    • In the four blocks below "Year", starting with the block at the far left, write in the year you were born.
    • Below each number you wrote in the block, fill in the circle with the number that matches the number you wrote in the block above.
  4. Home Phone **
    • In the blocks provided, starting with the block at the far left, write in your area code and home telephone number (or telephone number where we can reach you if you do not have a home phone).
    • Below each number you entered in the blocks, fill in the circle with the number that matches the number you wrote in the block above.
  5. Gender
    • Fill in the circle next to male if you are a man.
    • Fill in the circle next to female if you are a woman.
  6. County (Leave Blank)

  7. Educational Level
    • Fill in the circle that matches the highest education level you finished. (For example, if you have a high school diploma but do not have any college degree, fill in the circle next to "HS Diploma")
      HS = High school
      GED = General Educational Development
      DHSR-Alt Exam= Division of Health Service Regulation Alternate Exam
      Ass. Degree = Associate Degree
      Bach. Degree = Bachelor Degree
      Graduate Work = You have completed at least one graduate level course after receiving a Bachelor's Degree
  8. Aide Training
    • If you are registering for the Administrator or Alternative Exam, do not complete items 8 through 12; Skip to item 13.
    • Fill in the circle that matches the training program you have completed. If you have completed more than one level of training (for instance both a 20-hour course and a 40-hour course), only fill in the circle for the higher level of training (40 hrs.).
      CNA
      Fill in this circle if you have completed a nurse aide training program or if you are a certified nurse aide
      Other
      Fill in this circle if you have completed any other type of aide training not listed or if you have completed a licensed practical nursing program
  9. Medication Training
    • Fill in the circle that matches the medication training you have received.
    • Make sure you only fill in one circle for this item (if you have taken both a class on administering medications and have also completed the Medication Study Guide (PDF, 1.61 MB) developed by the Division of Health Service Regulation, fill in the circle beside Both
    • Fill in the circle for Class if you have received training in a group or individually.
  10. Currently Employed in a Facility
    • Fill in the appropriate response (fill in the circle for YES if you are now working in an adult care home, nursing home, hospital or mental health facility. Adult care home includes family care home and larger adult care. )
    • If you are not working in one of these facilities, fill in the circle for NO and skip to item # 13, "Home Mailing Address".
  11. Facility Employment
    • Fill in the appropriate circle. The list of initials for this item stand for the following:
      FCH
      Family Care Home
      HA
      Home for the Aged (Assisted Living)
      NH
      Nursing Home
    • If you do not now work in one of the facilities listed above, fill in the circle for "None of the above".
  12. Job Title in Facility
    • Fill in the circle that matches the title of the job you hold in the facility where you work.
    • If your title is not listed, fill in the circle beside "Other".


    Items 13-16 must be completed by applicants for all exams.

  13. Home Mailing Address **
    • Print your home mailing address in the blocks provided starting in the block at the far left.
    • Leave a space between the house/street number and the street name.
    • In the column below each number or letter you entered for your address, fill in the circle that matches the number or letter you wrote in the block above. For columns you have left a space, fill in the blank circle for that column.
    • Repeat the above steps for your city or town and state where you live.
  14. Zip Code **
    • Starting with the block in the far left, enter your 5-digit zip code. This is required.
    • If you know the 4-digit extension to your zip code, enter those numbers in the last four blocks. If you do not know the 4-digit extension to your zip code, leave the last four blocks empty.
    • In the column below each number you entered, fill in the circle of the number that matches the number you wrote in the block above.
  15. Type of Exam
    • Fill in the circle for the appropriate exam you are registering for: Administrator Exam; Medication Exam; or Alternative Exam
  16. Test Site Choices **
    For a current test schedule:
    Medication Aides: N.C. Medication Aide Testing website
    Administrator and Alternative Exam Applicants: Exam Schedule
    • This section will be used to schedule the location, day and time where you want to take our written test. From the test schedule provided, please choose three dates or exam codes that you could take the test.
    • From the test schedule provided, decide which test time is your first choice. Under the box that is marked "1st" fill in the circles that match the three digit code for your first choice. For instance if the code for your 1st choice is 001 -- in the far left column under the box heading "1st", fill in the zero, in the middle column in this box fill in the zero, and in the right column in this box fill in the one.
    • Repeat this process for your second choice (box titled 2nd) and your third choice (box titled 3rd).
    • Below each number you wrote in the block above, fill in the circle with the number that matches the number you wrote in the block above.
  17. Applicant Signature **
    • This box certifies that the information you have given is
      true and correct to the best of your knowledge.
    • Sign your name on the line provided
    • Enter the date you completed this form
    • Provide a current email address as an alternate means of contact
    • Enter the name of the facility you are employed and the facility’s fax number. This will help us contact you if any questions or if information needs to be faxed to you.

After completing items 1-17, mail the form to the Division of Health Service Regulation. Go to the top of the page under General Instructions for address and mailing instructions.

A confirmation letter will be mailed to you once you have been registered to take the written exam.

All applicants may check on registration by calling the Adult Care Testing Unit at 919-855-3793 or by e-mail AdultCare.ctu@dhhs.nc.gov.