One of the most important steps in helping your Indiana Department effectively manage personnel and ensure employee safety is to provide annual inservice training with updated forms. Keeping up with necessary paperwork can be tedious and time-consuming, but it’s essential for any organization that needs to keep their members up to date on policies, protocols, and regulations. With this comprehensive guide about the Indiana Department Annual Inservice Form, you will have a clearer understanding of how it works and why it matters.
Question | Answer |
---|---|
Form Name | Indiana Department Annual Inservice Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | QMA, CNA, qma study guide indiana, inservice |
QUALIFIED MEDICATION AIDE RECORD OF ANNUAL
State Form 51654 (R /
Approved by State Board of Accounts, 2009
INDIANA STATE DEPARTMENT OF HEALTH - DIVISION OF LONG TERM CARE
INSTRUCTIONS: 1. Please print or type clearly.
2.No abbreviations.
3.This form and fee must be submitted to ISDH by March 31.
4.The QMA is responsible for completing the
QMA Name: _______________________________________QMA Certification #:______________________
LastFirstM.I
Home Address: ___________________________________________________________________________
(street address (include Post Office box number, if applicable) City State ZIP code
Phone: __ ___/_________________ CNA Expiration Date*: __________________(CNA status MUST be current)
Payment (check one)*: _____Fee included OR _______Date paid online
Date
Topic
Location (facility name)
Length
(in ¼ hour
segments, i.e., 0.25, 0.50, 0.75, 1.0 hour)
Signature of Instructor*
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Approved |
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Not |
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Approved |
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Office Use Only
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Office Use Only TOTAL APPROVED HOURS: |
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REVIEWED BY: |
Date: |
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I submit the above information as proof of having met the six (6) hour per year
QMA Signature*: ___________________________________________
Date:___________________
*Mandatory information, form will be returned if * items are not completed.
For office use only:
Entered by:_______________________________
Receipt #
IMPORTANT NOTICE
CERTIFICATION/RECERTIFICATION/REINSTATEMENT and
QUALIFIED MEDICATION AIDE (QMA)
Effective January 1, 2005, the QMA certification process and
1.Be certified by the Indiana State Department of Health every year;
2.Obtain a minimum of six (6) hours per year of
3.Submit appropriate fee to Indiana State Department of Health with recertification request.
RECERTIFICATION:
At least 30 days prior to the expiration of the certificate, the individual must:
1.obtain a minimum of six (6) hours per year of annual
2.submit to the Indiana State Department of Health a qualified medication aide record of annual
3.submit to the ISDH the appropriate fee.
The QMA is responsible for completing the
REINSTATEMENT:
If the recertification fees and/or
1.complete an ISDH approved QMA course;
2.submit to the testing entity an application approved by the ISDH;
3.pass the written competency test in three (3) or fewer attempts with a passing score of 80%.
Annual
1.medication administration via
2.hemoccult testing;
3.finger stick blood glucose testing (specific to the glucose meter used).
QMA certificates are effective upon issue and expire on March 31 of the next year. The annual
Qualified Medication Aide Record of Annual
Indiana State Department of Health
Cashier’s Office
PO Box 7236
Indianapolis, IN
Failure to submit certification in a timely manner may result in additional fees or removal from the QMA registry. (Removal from the registry will require completion of a QMA course and passing of the QMA competency test for re- instatement).
If you have additional questions, please contact Gina Berkshire at gberkshire@isdh.in.gov or
or Nancy Gilbert at ngilbert@isdh.in.gov or