Doug Ducey Joey Ridenour
Governor Executive Director
Arizona State Board of Nursing
Certified Medication Assistant (CMA) Request for Waiver
APPLICANT INFORMATION
I hereby certify that the information provided is true and correct. I also certify that I have read Nurse Practice Act Statutes
ARS § 32-1650, 32-1650.01, 32-1650.02 and 32-1650.05, and understand the qualifications and responsibilities of a certified
medication assistant. (To see statutes, go to www.azbn.gov/NursePracticeAct.aspx
and click on CMA statute link)
Signature of Applicant for Waiver
WAIVER FOR NURSING STUDENTS AND
INSTRUCTOR VERIFICATION
WAIVER FOR CERTIFIED MEDICATION ASSISTANTS
AND EMPLOYER VERIFICATION
Required:
• A nursing course as part of an approved RN/LPN
program; which includes a block I or nursing
fundamentals course with theory and clinical
• A 3 credit pharmacology course
• Instructor verification that student spent a
minimum of 40 hours administering medications in
a long tern care facility.
Required:
• Verification from out of state registry sent directly
to AZBN showing evidence of completion of 100
hours of training in a CMA program.
• Proof that you have practiced as a medication
assistant in a long term care facility for at least 160
hours in the past two years OR completed a
medication assistant program in the past year.
Name and Address of School
Name of Facility submitting verification
Name of nursing fundamental
course
hours of course
Name of pharmacology course
hours of course
Dates of employment as Certified Medication Assistant
From: To:
Did student spend 40 hours in clinical administering
medications?
Yes No
Did applicant work at least 160 hours as a CMA?
Ye
s No
Signature of Instructor or Program Director attesting to the
veracity of the above information
Signature of Supervisor attesting to the veracity of the above
information
