Free 51118.pdf - Indiana

APPLICATION FOR APPROVAL OF THE QUALIFIED MEDICATION AIDE COURSE
State Form 51118 (10-02) Indiana State Department of Health ­ Division of Long Term Care

INSTRUCTIONS: Please complete the appropriate sections on both sides of the application. All applications must be completed in Sections A and D. SECTION A: Training program information
APPLICATION PURPOSE (check all that apply): ! Initial approval; ! Renewal; ! Add Instructor (Section B); ! Add Clinical Site (Section C); ! Remove Instructor: Name_____________________________________ Name of Facility:____________________________________________________________________________ Street Address:_____________________________________________________________________________ PO BOX #:________________________________________________________________________________ City:________________________________________________________________State_________________ ZIP:_________________________Phone number:______________________Fax number:________________

SECTION B:

Program Instructor information

Name:______________________________________________________________________________ Nursing License #:______________________________ Vocational License #:_____________________ A copy of the license MUST accompany this application

PLEASE PROVIDE SPECIFIC DATES & LOCATIONS FOR THE FOLLOWING:
QUALIFICATIONS:

A COPY OF THE Q.M.A. TRAIN-THE-TRAINER COURSE CERTIFICATE MUST ACCOMPANY THIS APPLICATION

SECTION C:

Practicum Sites

Name of Facility:___________________________________________________________________________ Address:_____________________________________________City_________________________________

Name of Facility:___________________________________________________________________________ Address:_____________________________________________City_________________________________

Name of Facility:___________________________________________________________________________ Address:_____________________________________________City_________________________________

SECTION D: Certification of QMA Program
I certify the above information is correct and the named facility/school in Section A will abide by the criteria set forth by 412 IAC 2.

_________________________________________________________

_____________________

Administrator of facility OR Director of non-facility based program

Date

Mail completed application, along with requested documentation to: INDIANA STATE DEPARTMENT OF HEALTH DIVISION OF LONG TERM CARE 2 N. MERIDIAN ST., 4B INDIANAPOLIS, IN 46204
Please use additional applications for more than one director. Also, keep a copy of this application for your records.