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Actor Training Affidavit and Confidentiality/Nondisclosure Agreement Application

BECOMING AN ACTOR:

To become an Actor, you must review and be trained with the Actor Training Materials by a certified RN Test Observer. You must also meet the criteria listed below. After accomplishing these tasks, you may then be used as an Actor.

To qualify as an Actor, you must meet the following criteria:

Actors need to understand that they are not able to sit for the Mississippi NA competency test for six (6) months from the date that they last worked as an Actor.
Actors must be of legal working age in Mississippi. Minors must also have a work permit where required by State law.
Actors must be trained and certified with these approved materials.
An Actor may NOT be a Nurse Aide Test Candidate who has not been tested.
An Actor may NOT be a student in any NA Training Program.
An Actor may NOT be the Nurse Aide Test Candidate's instructor.
Actors can be registry active NAs, testing team family members, volunteers, etc.

Once you have completed all of the fields within this document, select “Send Application" to submit your application.

Legal First Name

Middle

Legal Last Name

Birthdate

Phone

Gender

Male Female Other

Address

City

State

Zipcode

RN Test Observer Name

Name of RN Test Observer Please enter the name of the RN Test Observer above with whom you have reviewed the Actor Training Materials.

Affidavit

As a nurse aide skill test Actor, I swear that I have reviewed the Actor Training Materials with the RN Test Observer named, and I understand and will abide by the approved material presented. Click to open: Link to Actor Training Guidelines.

I understand that as an actor, I will not be permitted to apply and take the State Nurse Aide exam for 6 months from the date that I last worked as an actor.

CONFIDENTIALITY/NONDISCLOSURE AGREEMENT:
I acknowledge the confidential nature of the nursing assistant competency examination, including the materials, processes, procedures, and content of the 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, nor will I disclose any test content, examination results, or information about any Nurse Aide candidate's performance with instructors or administrators of any training facility, program, or with anyone else other than the RN Test Observer, D&SDT-HEADMASTER staff, or the appropriate State agency.
I will not be involved in testing family members or close personal friends, except in emergency situations as provided for in the D&SDT-HEADMASTER and State Guidelines.

TEST SECURITY:

I will maintain and never violate the tests' security or compromise any testing information. I understand that if I violate test security, I will be held legally accountable and prosecuted to the full extent of the law.

By Submitting

I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.