Embarking on a career as a Qualified Medication Aide (QMA) in Indiana requires a thorough preparation and adherence to specific protocols. One pivotal aspect of this journey involves completing and submitting the State Form 17213, a document facilitated by the Indiana State Department of Health designed for long-term care practitioners. This form serves a multifaceted purpose, including capturing the applicant's personal information, detailing the requisite education and practicum hours, and ultimately, verifying the applicant's qualifications. Comprising various sections, the form requests detailed information from the applicant, such as legal identity and contact information, alongside a privacy notice regarding the voluntary provision of Social Security Numbers. Education and practical training sections further require course details, facility affiliations, instructor validations, and verification of successful completion. Additional sections solicit information regarding the candidate's status, necessary documentation for testing eligibility—highlighting the $60 money order fee requirement—and procedure for documenting test results. This comprehensive form, requisite for potential QMAs, underscores the rigorous standards set forth by Indiana's health regulatory authorities to ensure qualified, competent professionals enter the field.
| Question | Answer |
|---|---|
| Form Name | State Form 17213 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 17213 empire auto parts browser form |
INDIANA STATE DEPARTMENT OF HEALTH
LONG TERM CARE
Test Application for Qualified Medication Aide
State Form 17213
Form approved by State Board of
SECTION 1: APPLICANT INFORMATION
Applicant's LEGAL Name:_______________________________________________________ Sex: _____F _____ M
LastFirstM.I.
Address:______________________________________________________________ Phone#: (___)_____________
City, State, Zip: ________________________________________________________ County: __________________
Birth Date: __________________ CNA Registry #: ________________________ SS#: ________________________
*PRIVACY NOTICE TO APPLICANT: The Indiana State Department of Health is requesting disclosure of your Social Security Number to accomplish its purpose under
SECTION 2: COURSE INFORMATION (60 HOUR CLASSROOM EDUCATION)
Facility/School Name (no abbreviations):______________________________________ Phone#: (___)_____________
Address:_________________________________________________________ ISDH QMA Training #: __________
City, State, Zip: ________________________________________________________ County: __________________
Date of Classroom Completion: ___________ RN Instructor's PRINTED Name: ______________________________
I verify that the above named applicant has successfully completed at least 60 hours of classroom instruction using ISDH approved training materials and that a summary of all assessment tools and checklists are completed and available in this applicant's file.
____________________________________________ |
_____________________________ |
_______________ |
RN Instructor's Signature (must be in red ink) |
RN Instructor's License # |
Date |
SECTION 3: COURSE INFORMATION (40 HOUR PRACTICUM)
Facility Name: _________________________________________________________ Phone#: (___)_____________
Address:_________________________________________________________ ISDH QMA Training #: __________
City, State, Zip: ________________________________________________________ County: __________________
Date of Practicum Completion: ___________ Nurse Supervisor's PRINTED Name: ____________________________
I verify that the above named applicant has, under my supervision, successfully completed at least 40 hours of practical experience administering medications and performing procedures according to ISDH approved training materials.
____________________________________________ |
_____________________________ |
_______________ |
Nurse Supervisor's Signature (must be in red ink) |
Nurse License # |
Date |
SECTION 4: APPLICANT VERIFICATION
I verify that all of the above information is correct. I understand that falsification of this document may result in denial or revocation of my qualification.
Applicant's Signature: _______________________________________________________ Date: _________
SECTION 5: CANDIDATE STATUS
□ 100 HOUR CLASS |
□ |
□ Psychiatric Attendant |
□ Nursing Student - School: ______________________________________ |
□ Other: _________________________ |
□ Foreign Nurse - Country: ______________________________________ |
|
|
|
SECTION 6: DOCUMENTATION |
The following required documents are included with this request to test: |
|
□ Original Application |
□ Copy of High School Diploma, GED or transcript |
□ Original documentation of practicum |
□ Copy of current Indiana Nurse Aide Registry certification letter |
Nursing Students and
□ Original ISDH approval letter & all documentation initially submitted to ISDH
Include testing fee of $60.00 (money order) payable to Professional Resources. Personal checks are not accepted. Send all documentation and fee to: Professional Resources, PO Box 1552, Valparaiso, IN
FIRST TESTING |
SECTION 7: TEST RESULTS |
Test Entity |
|
Tester
Test Date
Test Site
County
WRITTEN TEST RESULTS: |
PASS ______ |
FAIL _______ |
SCORE:_______
SECOND TESTING
Test Entity
Tester
Test Site
Test Date
County
WRITTEN TEST RESULTS: |
PASS ______ |
FAIL _______ |
SCORE:_______
THIRD TESTING
Test Entity
Tester |
|
|
Test Date |
|
|
|
|
Test Site |
|
|
County |
|
|
|
|
WRITTEN TEST RESULTS: |
PASS ______ |
FAIL _______ |
SCORE:_______ |
|
|
|
|