Important changes per Indiana State Department of Health 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name clearly in the designated field (Last, First, Middle Initial). This ensures accurate identification.
3. Input your QMA Certification Number. This is crucial for verifying your qualifications.
4. Fill in your address, including the number and street, city, state, and ZIP code. Make sure all information is correct for future correspondence.
5. Provide your telephone number with the area code for any necessary follow-up communications.
6. Enter the date of training completion in the format mm/dd/yy to maintain consistency.
7. List the topic of training related to medications or QMA Scope of Practice only. This keeps your record focused and relevant.
8. Have the instructor sign and include their credentials in the appropriate section to validate the training received.
9. Indicate the length of training completed in quarter-hour increments for precise documentation.
10. Finally, ensure you sign and date the form at the bottom as a confirmation of accuracy before saving or printing it.

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