Fillable Printable Form 5165
Fillable Printable Form 5165
Form 5165
QUALIFIED MEDICATION AIDE (QMA) RECORD OF ANNUAL IN-SERVICE TRAINING
State Form 51654 (R2 / 5-13)
Approved by State Board of Accounts, 2013
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.
Name of QMA (last, first, middle initial)
QMA Certification number
Home address (number and street, city, state, and ZIP code)
Telephone number (include area code)
CNA Expiration date (CNA status must be current) (date, month, year)*
Payment (check one only)* Fee included Date paid online
Check all that apply and complete date in-service provided, length of time for each (in ¼ hour segments ONLY, I.E., .25, .50, .75,
1.0) and Instructor’s signature *MUST BE AN ORIGINAL SIGNATURE. (Form must be mailed to Indiana State Department
of Health (ISDH) / no faxes / no scan-email.)
Name of facility where you work (no abbreviations)*
Did facility provide the in-service?* Yes No
If No, who provided them and where did you receive them?*
Only acceptable in-service form for QMA renewal as of 12/31/2013.
*In-service dates: March 1
st
of previous year to February 28
th
/29
th
of current year
TOPIC
(Suggested)
DATE
(month, day, year)
LENGTH
OF TIME
INSTRUCTOR’S
SIGNATURE / TITLE
ISDH
Approved / Not Approved
Lesson 51 Approved Not Approved
Lesson 52 Approved Not Approved
Lesson 53 Approved Not Approved
Lesson 54 Approved Not Approved
Lesson 55 Approved Not Approved
Lesson 56 Approved Not Approved
Lesson 57 Approved Not Approved
Lesson 58 Approved Not Approved
Lesson 59 Approved Not Approved
Lesson 60 Approved Not Approved
Lesson 61 Approved Not Approved
Lesson 62 Approved Not Approved
Lesson 63 Approved Not Approved
Reset Form
ADDITIONAL (MEDICATION RELATED) IN-SERVICES ATTENDED:
TOPIC
(Suggested)
DATE
(month, day, year)
LENGTH
OF TIME
INSTRUCTOR’S
SIGNATURE / TITLE
ISDH
Approved / Not Approved
1 Approved Not Approved
2 Approved Not Approved
3 Approved Not Approved
4 Approved Not Approved
5 Approved Not Approved
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. (Submitting fraudulent in-service hours may lead to denial of recertification.)
QMA signature*
Date (month, day, year)
*Mandatory information, form will be returned if items are not completed.
FOR ISDH USE ONLY
Total approved hours
Reviewed by:
Date (month, day, year)
Entered by:
Date (month, day, year)
Receipt number
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:
1. Obtain a minimum of six (6) hours per year of annual in-service education (acceptable in-service dates March 1-
February 28/29);
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 (documenting six (6) hours of in-service hours/dates noted above) 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.
***QMA Record of Annual In-service Training form MUST be mailed (No Fax/Email) to:
Indiana State Department of Health
Cashier’s Office
PO Box 7236
Indianapolis, IN 46207-7236
Make check/money order payable to Indiana State Department of Health.
Renew online, with credit card, at www.in.gov/pla/license.htm
.
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 the QMA competency test for re-
instatement.
If you have additional questions, please contact Gina Berkshire at 317-233-7497 or Nancy Gilbert at 317-233-7616.
