Printable Indiana Department Annual Inservice Form
Indiana Department Annual Inservice Sample
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
File Characteristics
| Fact Name | Details |
|---|---|
| Form Title | Qualified Medication Aide Record of Annual In-Service Training |
| Form Number | State Form 51654 (R / 11-09) |
| Approval Authority | Approved by State Board of Accounts in 2009 |
| Submission Deadline | The form and fee must be submitted to the Indiana State Department of Health by March 31 each year. |
| In-Service Education Requirement | QMAs must complete a minimum of six hours of annual in-service education related to medication administration. |
| Governing Law | Indiana Administrative Code 412 IAC 2-1-10 outlines the certification and in-service education requirements for QMAs. |
| Reinstatement Conditions | If recertification is not completed within 91 days after expiration, the individual must complete an approved QMA course and pass a competency test for reinstatement. |
| Payment Information | A fee of $10.00 is required, payable by check or money order to the Indiana State Department of Health. |
| Contact Information | For questions, contact Gina Berkshire at gberkshire@isdh.in.gov or Nancy Gilbert at ngilbert@isdh.in.gov. |
Essential Points on This Form
What is the purpose of the Indiana Department Annual Inservice form?
The Indiana Department Annual Inservice form, known as the Qualified Medication Aide Record of Annual In-Service Training, is used to document the completion of required in-service education for Qualified Medication Aides (QMAs). Each year, QMAs must complete a minimum of six hours of training related to medication administration and submit this form along with the appropriate fee to the Indiana State Department of Health (ISDH) by March 31.
What are the requirements for completing the in-service education?
To fulfill the in-service education requirements, QMAs must:
- Complete at least six hours of in-service education annually.
- Ensure that the training relates specifically to medication administration.
- Submit the completed form and a fee of $10.00 to the ISDH by the deadline.
Additionally, if a QMA performs specific tasks like G-tube/J-tube medication administration, hemoccult testing, or finger stick blood glucose testing, those topics must also be included in their training.
What happens if I miss the submission deadline?
Failure to submit the form and fee by the March 31 deadline may result in additional fees or removal from the QMA registry. If removed, you will need to complete an ISDH-approved QMA course and pass the competency test to regain your certification.
How do I submit the form and payment?
To submit your Qualified Medication Aide Record of Annual In-Service Training form and payment:
- Complete the form clearly, ensuring all mandatory information is filled out.
- Include a check or money order for $10.00 made payable to the Indiana State Department of Health.
- Mail both items to:
- Indiana State Department of Health
- Cashier’s Office
- PO Box 7236
- Indianapolis, IN 46207-7236
Who can I contact for further questions?
If you have additional questions, please reach out to:
- Gina Berkshire at gberkshire@isdh.in.gov or call 317/233-7497.
- Nancy Gilbert at ngilbert@isdh.in.gov or call 317/233-7616.
Misconceptions
Understanding the Indiana Department Annual Inservice form is crucial for Qualified Medication Aides (QMAs). Here are six common misconceptions about this form:
- The form can be submitted at any time during the year. This is incorrect. The form and fee must be submitted by March 31 each year.
- Abbreviations are acceptable on the form. No, the instructions clearly state that no abbreviations are allowed. All information must be printed or typed clearly.
- Only the QMA needs to complete the form. While the QMA is responsible for the submission, they must also ensure that the instructor's signature is included, confirming the completion of the in-service training.
- Six hours of in-service education is optional. This is a misconception. All QMAs are required to complete a minimum of six hours of in-service education each year.
- Payment is not necessary if the form is submitted on time. This is false. The appropriate fee must be submitted along with the form, regardless of the submission timing.
- In-service education topics can be unrelated to medication administration. This is not true. The annual in-service education must specifically relate to medication and/or medication administration.
By addressing these misconceptions, QMAs can better understand their responsibilities and ensure compliance with the Indiana State Department of Health requirements.
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