Are you looking to get registered with State Form 17213? If so, then you have come to the right place! Understanding this form and the process involved can be extremely daunting, but don't worry - we are here to help make it simple and straightforward. In this blog post, we will provide a detailed overview of exactly what is required to fill out State Form 17213 correctly and successfully. From gathering important documents for registration, understanding all applicable fees that must be paid upfront, as well as ways in which you can avoid any potential pitfalls throughout the process - by keeping reading you'll have everything you need to know about completing your State Form 17213 registration quickly and accurately.
| 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: ______________________________________ |
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SECTION 6: DOCUMENTATION |
The following required documents are included with this request to test: |
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□ 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 |
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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 |
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Test Date |
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Test Site |
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County |
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WRITTEN TEST RESULTS: |
PASS ______ |
FAIL _______ |
SCORE:_______ |
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