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Form preview Indiana qma curriculum form QUALIFIED MEDICATION AIDE RECORD OF ANNUAL IN-SERVICE TRAINING State Form 51654 R / 11-09 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 in-service education requirements maintaining documentation of inservice education and submitting or ensuring the submission of the qualified medication aide record of annual inservice education form and appropriate fee. QUALIFIED MEDICATION AIDE RECORD OF ANNUAL IN-SERVICE TRAINING State Form 51654 R / 11-09 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 in-service education requirements maintaining documentation of inservice education and submitting or ensuring the submission of the qualified medication aide record of annual inservice education form and appropriate fee. Annual in-service education MUST relate to medication and/or medication administration* If a QMA performs medication administration via a G-tube/J-tube hemoccult testing finger stick blood glucose testing annual in-service must be done yearly. QMA Name QMA Certification Last First M. 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 Office Use Only Topic Location facility name TOTAL APPROVED HOURS Length Signature of Instructor in hour segments i*e* 0. 25 0. 50 0. 75 1. 0 hour Approved Not REVIEWED BY I submit the above information as proof of having met the six 6 hour per year in-service requirement and hereby apply for re-certification* QMA Signature Date For office use only Mandatory information form will be returned if items are not completed* Entered by Receipt IMPORTANT NOTICE CERTIFICATION/RECERTIFICATION/REINSTATEMENT and IN-SERVICE EDUCATION REQUIREMENTS FOR Effective January 1 2005 the QMA certification process and in-service education requirement is mandatory every year. This is in accordance with Indiana Administrative Code 412 IAC 2-1-10. Under this rule all QMAs must meet the following three 3 requirements 1. Be certified by the Indiana State Department of Health every year 2. Obtain a minimum of six 6 hours per year of in-service education in the area of medication administration and 3. Submit appropriate fee to Indiana State Department of Health with recertification request. At least 30 days prior to the expiration of the certificate the individual must 2. submit to the Indiana State Department of Health a qualified medication aide record of annual in-service education on the form approved by the ISDH and education and submitting or ensuring the submission of the qualified medication aide record of annual in-service education form and appropriate fee.

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