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NURSE AIDE: Primary Nurse Aide Instructor Login Request Form Application

Please complete this form if you are a Arkansas Department of Health (DHS)-approved Primary Instructor in a Nurse Aide Training Program in Arkansas and would like to access TMU.

NOTE: If you are an instructor for multiple training programs, please list the programs and upload your documentation under the Nurse Aide Training Program Affiliation section.

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

Legal First Name

Middle

Legal Last Name

Birthdate

Phone

Address

City

State

Zipcode

RN License Information

License Number

Expires

Nurse Aide Training Program Affiliation

Name of Nurse Aide Training Program Please select your training program from the drop-down list.

Upload documentation showing that you are a DHS-approved Primary Instructor for the above listed program.

Are you a DHS-approved Primary Instructor for other programs?

If you selected YES, that you are a DHS-approved Primary Instructor for other programs, please list each program.

If you selected YES, that you are a DHS-approved Primary Instructor for other programs, please upload your documentation for the additional programs you listed above (you may upload multiple documents if needed.)

Affidavit

I have uploaded my documentation showing that I am a DHS-approved nurse aide Primary Instructor.
If I am an instructor for multiple programs, I have listed those programs and uploaded my documentation showing that I am a DHS-approved nurse aide Primary Instructor.

By Submitting

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