Submit New Application

MN STATE ONLY: RN Test Observer Application

NOTE: Headmaster TASE-RN test observers will not use this application. This application is for MN State RN test observers only.  

Please fill out this application and upload the following documentation in the appropriate sections:
  • An updated resume detailing your one-year experience providing care for the elderly or chronically ill of any age 
  • Verification of your current RN Nursing License with an expiration date from the MN Board of Nursing website.
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 the ACTOR TRAINING GUIDELINES
Click to open the KNOWLEDGE TEST PROCTOR (KTP) GUIDELINES
Click to open the TEST SITE EQUIPMENT LIST (1503 MN)

Once you have completed all the fields and uploaded the required documents within this application, select 'Send Application' to submit your application.
Address
RN License Information
WORK EXPERIENCE VERIFICATION
REFERENCE
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 students I have trained, 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 RN Test Observer, I acknowledge and certify that I have provided and reviewed and will abide by the Actor training material 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://mn.tmutest.com/apply
  • I understand that persons used as Actors or Knowledge Test Proctors (KTPs) are under my supervision. 
  • I also understand that any Actor or Knowledge Test Proctor I choose to use will not be eligible to sit for the nurse aide competency test for 6 months from the date they last helped during a nurse aide test event.
TEST SITE EQUIPMENT LIST AND RN TEST OBSERVER AFFIDAVIT (1503 MN):  
I hereby certify that I will ensure that all necessary materials and equipment are available to consistently administer the Nurse Aide Knowledge/Audio and/or Skill tests as listed on the Minnesota Form 1503MN, the RN Test Observer/Test Site Equipment List Affidavit.
  • If all necessary materials and equipment are unavailable or properly operable, I will report missing or inoperable test site equipment by listing it in TMU© under the test discrepancies before submitting my test event observations for scoring.
  • I will carry at least the minimum equipment/supplies listed on the Additional Equipment Normally Provided by RN Observer for each test event I manage.
I have uploaded the required documentation with this application, which includes:
  • Resume 
  • Verification of my current RN Nursing License with an expiration date from the MN Board of Nursing website
By Submitting
I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.
1.800.393.8664