TX HHS Form 5541. Corrections Medication Aide Program General Statement Enrollment

Form 5541 serves as the enrollment application for the Corrections Medication Aide Program administered by the Texas Health and Human Services Commission (HHSC). This form is essential for individuals aiming to train and become certified as medication aides specifically in correctional settings, ensuring they can safely administer medications under regulated guidelines.

Purpose of the Form

The primary purpose of Form 5541 is to facilitate the application process for enrollment in an approved training program for corrections medication aides. It collects necessary personal, employment, and eligibility information to determine if applicants meet the criteria for participation. Upon approval, it leads to examination and potential issuance of a permit, allowing the holder to perform medication administration duties in correctional facilities while adhering to state rules and practices.

Who Uses the Form and When It Is Needed

This form is used by individuals who are at least 18 years old, employed in a correctional facility or by a medical service contractor for such facilities, and seeking certification as a corrections medication aide. It is particularly relevant for employees in Texas correctional systems who need to handle medication distribution safely and legally. The form is required when enrolling in an HHSC-approved training school for the program. Situations where it is needed include starting a new role involving medication administration in prisons or jails, career advancement in correctional healthcare, or compliance with occupational licensing under Texas regulations. Applicants must submit the form no later than 20 days after the first scheduled class date to avoid processing delays.

Requirements for Submission

To process the application, all sections must be fully completed, and it must include a $15.00 nonrefundable application fee payable to the Texas Health and Human Services Commission (HHSC). Incomplete applications, missing fees, or absent documentation will prevent processing. Additionally, applicants must provide a certified copy or a non-notarized photocopy of a high school diploma, transcript, or general equivalency diploma (GED). A mandatory fingerprint-based criminal history check through the Texas Department of Public Safety (DPS) is required before approval for examination; instructions are available via the DPS website or by contacting FAST at 888-467-2080, with a service code obtained from the Medication Aide Program email. Failure to complete this check can delay or deny the application. Applicants must also confirm receipt of the Medication Aide Training Program Rules, obtainable from the training program or HHSC office.

Sections and Data Requested

The form is structured to gather comprehensive details across several key areas, ensuring applicants meet educational, health, legal, and professional standards.

Personal Information

This section requires basic identifying details, including:

• Name (last, first, middle initial)
• Date of Birth
• Social Security Number
• Home Area Code and Phone Number
• Email Address
• Mailing Address (Street or P.O. Box, City, State, ZIP Code)

Training Program Details

Applicants must provide information about their chosen training:

• Name of Approved Training School
• City, State, and ZIP Code of the Approved Training School
• Date of First Scheduled Class of Instruction

Eligibility Questions

A series of yes/no questions assess basic qualifications:

• Are you able to read, write, speak, and understand English?
• Are you at least 18 years old?
• Are you employed in a correctional facility or by a medical service contractor for a correctional facility? (If yes, include first date of employment)
• Are you, to the best of your knowledge, free of contagious diseases and in suitable physical and emotional health to safely administer medications?
• Have you been convicted of a criminal offense listed in Occupational Code Chapter 53, which applies to an HHSC license? (If yes, provide conviction details and date)
• Have you received a copy of the Medication Aide Training Program Rules? (If no, instructions to obtain one are provided)

Acknowledgment and Agreement

This section includes a detailed statement where the applicant agrees to:

• Abide by the Medication Aide rules
• Complete all application requirements and examinations
• Be bound by the Allowable and Prohibited Practices of a Permit Holder (TAC 557.105) upon permit issuance
• Understand that submitted materials become HHSC property and are non-returnable
• Acknowledge the schedule of fees (TAC 557.109(c)) and the need for additional fees to maintain the permit
• Return the permit to HHSC if denied, suspended, or revoked
• Certify that all provided information is truthful, with awareness that falsification may void the application, prevent permit issuance, or lead to revocation

The applicant must sign and date this section.

Notarization

The form requires notarization to verify the applicant's identity and statements. It includes fields for:

• State and County
• Applicant's appearance before the notary
• Notary's acknowledgment of the execution and truthfulness
• Notary's signature, printed name, commission expiration date, and seal/stamp

Submission Instructions

Completed forms should be mailed to: Medication Aide Program, P.O. Box 149030, Mail Code E-416, Austin, Texas 78714-9030.

Privacy and Rights Information

The form includes a notice on privacy rights under Texas Government Code, stating that individuals have the right to request, review, and correct information obtained by HHSC about them (Sections 552.021, 552.023, 559.004). For inquiries, contact the Long-Term Care Regulatory Medication Aide Program at 512-438-2025.

Key Form Details

Form Name: Corrections Medication Aide Program General Statement Enrollment
Form Number: 5541
Region/Organization: Texas Health and Human Services Commission (HHSC)
Edition Date: November 2022