Create Your Indiana Department Annual Inservice

Fillable Indiana Department Annual Inservice Form

The Indiana Department Annual Inservice form is a crucial document for Qualified Medication Aides (QMAs) that records their annual in-service training. This form must be completed accurately and submitted to the Indiana State Department of Health by March 31 each year. It ensures that QMAs meet the necessary educational requirements related to medication administration and maintain their certification status.

To ensure compliance, fill out the form by clicking the button below.

Create Your Indiana Department Annual Inservice

Overview

Documents used along the form

When working with the Indiana Department Annual Inservice form, several other documents are often required to ensure compliance and proper record-keeping. These documents support the certification and training process for Qualified Medication Aides (QMAs) and help maintain standards within the healthcare system. Below is a list of related forms and documents that may be necessary.

Qualified Medication Aide Training Course Completion Certificate: This certificate verifies that the QMA has successfully completed an approved training course, which is a prerequisite for certification.
QMA Certification Application: This application must be submitted to the Indiana State Department of Health to obtain initial certification as a Qualified Medication Aide.
In-Service Education Documentation: This record includes details of all in-service training sessions attended by the QMA, including dates, topics, and instructors, to ensure compliance with annual training requirements.
Recertification Application: This application is submitted to renew the QMA certification and must include proof of completed in-service education hours and applicable fees.
Payment Receipt: A copy of the payment receipt for the certification or recertification fees is often required to confirm that the necessary fees have been paid to the Indiana State Department of Health.
Ohio Motorcycle Bill of Sale Form: To ensure your motorcycle transactions are documented correctly, refer to our comprehensive Motorcycle Bill of Sale documentation guide for a thorough understanding of the requirements.
Competency Test Results: These results demonstrate that the QMA has passed the required competency test, which assesses knowledge and skills related to medication administration.
Facility Policy Acknowledgment: This document confirms that the QMA is aware of and understands the policies of the facility regarding medication administration and related procedures.
Annual Evaluation Form: This form is used by the facility to evaluate the QMA's performance and adherence to medication administration protocols, which can be beneficial for ongoing training and compliance.

Understanding these documents and their purposes can streamline the certification and recertification process for QMAs. Staying organized and ensuring timely submissions will help maintain compliance with state regulations and support the delivery of safe and effective care.

Common mistakes

Illegible handwriting: Many individuals fail to print or type clearly, leading to confusion and potential errors in processing the form.
Using abbreviations: Some people mistakenly use abbreviations, which can result in misunderstandings or misinterpretations of the information provided.
Missing submission deadline: The form must be submitted by March 31. Late submissions can incur additional fees or lead to removal from the QMA registry.
Incomplete required information: Failing to complete mandatory fields, such as QMA name, certification number, or signature, will result in the form being returned.
Incorrect payment method: Some individuals may not check the correct payment option or fail to include the required fee, leading to processing delays.
Not documenting in-service education: It is crucial to maintain documentation of in-service education. Missing this can affect recertification.
Inaccurate topic or length: Providing incorrect information about the topic or length of in-service education can lead to disapproval of hours claimed.
Failure to update CNA status: The CNA expiration date must be current. An expired status can result in the rejection of the application.
Ignoring office use sections: Not filling out the sections intended for office use can lead to confusion during processing and may delay approval.

⇓ Indiana Department Annual Inservice File

Key takeaways

Filling out the Indiana Department Annual Inservice form is a crucial step for Qualified Medication Aides (QMAs) to maintain their certification. Here are some key takeaways to keep in mind:

Clear Printing Required: Always print or type your information clearly on the form to avoid any misunderstandings.
No Abbreviations: Use full words instead of abbreviations to ensure clarity.
Submission Deadline: Submit the form and fee by March 31 each year to remain compliant.
Education Responsibility: QMAs must complete in-service education requirements and maintain documentation of their training.
Relevant Topics: Annual in-service education must relate to medication and/or medication administration.
Specific Procedures: If performing specific tasks like G-tube administration or blood glucose testing, ensure these are included in your training.
Certification Status: Confirm that your CNA status is current before submitting the form.
Fee Submission: Include the appropriate fee, which is $10, either by check or money order made out to the Indiana State Department of Health.
Documentation: Keep a copy of the completed form and any related documents for your records.
Contact Information: For questions or clarifications, reach out to the provided contacts at the Indiana State Department of Health.

By following these guidelines, QMAs can ensure a smooth process in maintaining their certification and fulfilling their professional responsibilities.

Form Breakdown

Fact Name	Details
Form Title	Qualified Medication Aide Record of Annual In-Service Training
Form Number	State Form 51654 (R / 11-09)
Governing Law	Indiana Administrative Code 412 IAC 2-1-10
Submission Deadline	Form and fee must be submitted by March 31 each year.
In-Service Requirement	A minimum of six (6) hours of in-service education is required annually.
Payment Details	Fee of $10.00, payable by check or money order to Indiana State Dept. of Health.
Contact Information	For questions, contact Gina Berkshire at gberkshire@isdh.in.gov or Nancy Gilbert at ngilbert@isdh.in.gov.

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Form Example

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 in- service education, and submitting, or ensuring the submission of, the qualified medication aide record of annual in- service 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 #:______________________

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*

	Approved		Not
			Approved

Office Use Only
















Office Use Only TOTAL APPROVED HOURS:	REVIEWED BY:	Date:

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:___________________

*Mandatory information, form will be returned if * items are not completed.

For office use only:

Entered by:_______________________________

Date:_______________-____________________

Receipt #

IMPORTANT NOTICE

CERTIFICATION/RECERTIFICATION/REINSTATEMENT and IN-SERVICE EDUCATION REQUIREMENTS FOR

QUALIFIED MEDICATION AIDE (QMA)

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.

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 in-service education;

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

3.submit to the ISDH the appropriate fee.

The QMA is responsible for completing the in-service education requirements, maintaining documentation of in-service education, and submitting, or ensuring the submission of, the qualified medication aide record of annual in-service education form and appropriate fee.

REINSTATEMENT:

If the recertification fees and/or in-service education form is received by the ISDH ninety-one (91) or more days after expiration of the QMA certification, the individual is removed from the QMA registry and must be reinstated. For reinstatement as a QMA following removal from the QMA registry, the individual must:

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%.

IN-SERVICE EDUCATION REQUIREMENTS:

Annual in-service education shall include medication administration. If facility policy allows the QMA to perform such functions in the facility, annual in-service education shall also include:

1.medication administration via G-tube/J-tube;

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 in-service education requirement period begins each year on March 1 and concludes on the last day of February of the next year. In the case of an initial certificate, the annual in-service education requirement period begins on the QMA certification effective date and concludes on the last day of February of the next year. The in-service education requirement period therefore ends one (1) month prior to the expiration of the certification.

Qualified Medication Aide Record of Annual In-service Training form and fee ($10.00 check or money order payable to Indiana State Dept. of Health) should be submitted to ISDH. The form and fee must be sent to:

Indiana State Department of Health

Cashier’s Office

PO Box 7236

Indianapolis, IN 46207-7236

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 317/233-7497

or Nancy Gilbert at ngilbert@isdh.in.gov or 317/233-7616.