State 17213 Form in PDF

What is the purpose of the State Form 17213?

State Form 17213, issued by the Indiana State Department of Health, serves as the Test Application for Qualified Medication Aide (QMA) certification. Its primary purpose is to facilitate the application process for individuals seeking to become certified as Qualified Medication Aides in Indiana. By completing this form, applicants are taking the first step towards certification, which involves verifying their completion of the requisite training programs and eligibility to sit for the certification examination.

Who needs to complete the State Form 17213?

This form must be completed by individuals who have successfully finished the required classroom and practicum training to become a Qualified Medication Aide in Indiana and are ready to take the certification test. The form is applicable to a wide range of candidates, including but not limited to, current nursing students, psychiatric attendants, out-of-state Qualified Medication Aides seeking certification in Indiana, and foreign-trained nurses.

What are the required documents to be submitted along with State Form 17213?

Along with the completed application form, candidates must submit several documents as part of their application package. These include the original application form, a copy of their high school diploma, GED, or transcript, original documentation of their practicum completion, and a copy of their current Indiana Nurse Aide Registry certification letter. Candidates who are nursing students or out-of-state Qualified Medication Aides must also include an original Indiana State Department of Health approval letter and all documentation that was initially submitted to ISDH. It's important to note that a testing fee of $60, payable via money order to Professional Resources, is also required. Personal checks are not accepted.

How is the testing fee for the State Form 17213 certification test paid?

The testing fee, which amounts to $60, must be paid through a money order made payable to Professional Resources. The form, along with the necessary documentation and the testing fee, should be sent to Professional Resources at the specified address. It's crucial to remember that personal checks are not accepted for the payment of this fee.

What happens after submitting the State Form 17213?

After submitting the State Form 17213 along with all the required documentation and the testing fee, candidates are scheduled for the certification test. The test results are provided in three sections: first testing, second testing, and third testing, if applicable. Each section documents the test entity, tester, test site, test date, county, and the candidates' results — indicating whether they passed or failed, along with their scores.

Can someone be penalized for not providing their Social Security Number on the State Form 17213?

No, applicants are not penalized for withholding their Social Security Number on the State Form 17213. The Indiana State Department of Health requests the disclosure of an applicant’s Social Security Number under IC4-1-8 for identification purposes. However, disclosure is voluntary, and applicants have the right to refuse without facing any penalties.

Filling out State Form 17213, required for a Qualified Medication Aide (QMA) certification in Indiana, demands careful attention to detail. Common mistakes can lead to processing delays or even the denial of certification. It's beneficial for applicants to be mindful of these pitfalls to ensure a smooth application process.

The first frequent error occurs in Section 1, where applicants must provide their legal name. Often, individuals may unintentionally use nicknames or abbreviations, which can lead to verification issues, as this information must match other legal documents precisely.

In Section 2, regarding course information, a common mistake is not providing the full name of the facility or school where the classroom education took place. Abbreviations or informal names can complicate the verification process, thereby hindering the application. Moreover, the diligent verification of the RN instructor's signature in red ink is crucial. This specific requirement, if overlooked, can invalidate the section.

Another slip-up takes place in Section 3, where details of the practicum are documented. The nurse supervisor's license number and signature in red ink are often incorrectly provided or entirely missed. This documentation is vital for confirming the practical experience component of the certification.

Section 4's verification by the applicant is a step frequently bypassed. Applicants must understand that this section's accuracy is paramount and falsification can lead to serious consequences, including denial or revocation of the qualification.

Section 5, which outlines the candidate status, is another area where errors are common. Failure to accurately indicate the applicable status, such as out-of-state QMA or nursing student, can mislead the reviewing department, leading to unnecessary back-and-forth and potential rejection.

Including all necessary documentation as listed in Section 6 is crucial. Applicants often forget one or more of the following required documents:

1. The original application;
2. A copy of a high school diploma, GED, or transcript;
3. Original documentation of the practicum;
4. A copy of the current Indiana Nurse Aide Registry certification letter.

Especially for nursing students and out-of-state QMAs, the omission of the original ISDH approval letter and accompanying documentation initially submitted to ISDH can significantly delay the process. Additionally, overlooking the requirement to include the testing fee with a money order, rather than a personal check, is a simple but frequent oversight.

Last but not least, applicants often neglect to send the complete package to the correct address, as specified. This may seem trivial, but incorrect or incomplete addresses can lead to lost applications or further delays. Ensuring the completeness and accuracy of the application package is essential for a successful certification process.

Being mindful of these common mistakes and adhering closely to the form's requirements will greatly assist applicants in achieving their goal of becoming a certified Qualified Medication Aide.

When completing the State Form 17213 for the Indiana State Department of Health's Long Term Care Test Application for Qualified Medication Aide, it is essential to have all necessary documents prepared and organized. This ensures a smoother application process, enhancing the chances for approval. Below is a list of other forms and documents often used alongside the State 17213 form, each serving a critical role in the completion and submission process.

• High School Diploma, GED, or Transcript: A copy of the applicant's high school diploma, GED, or high school transcript is required to prove they have met the basic educational qualifications needed for certification.
• Current Indiana Nurse Aide Registry Certification Letter: This document verifies the applicant's current status as a Certified Nursing Assistant (CNA), which is a prerequisite for becoming a Qualified Medication Aide (QMA).
• Original Documentation of Practicum: This includes detailed records of the 40-hour practicum under supervision, proving hands-on experience in administering medications and performing procedures according to approved training materials.
• ISDH Approval Letter: For nursing students and out-of-state QMAs, the original approval letter from the Indiana State Department of Health is necessary, alongside all documentation initially submitted for approval.
• Testing Fee Payment: A money order of $60.00 payable to Professional Resources is required. It is important to note that personal checks are not accepted, and this fee covers the cost associated with the testing process.

Gathering and preparing these documents along with the State Form 17213 is vital for a successful application and testing process. Applicants are reminded to review their application packet thoroughly to ensure completeness and accuracy before submission. This careful preparation can lead to a more straightforward and less stressful certification journey.

The State 17213 form is similar to other documents used in the healthcare and education sectors for certification or verification purposes. Each document, while serving a unique function, shares common elements with the State 17213 form, such as the collection of personal information, the requirement for educational prerequisites, and the need for verification from licensed professionals.

• National Council Licensure Examination (NCLEX) Application: Just like the State 17213 form, the NCLEX application gathers extensive applicant information, including educational background and personal details. Both forms serve as a gateway to professional certification within the healthcare field, albeit for different roles. The NCLEX application is focused on nurses seeking licensure to practice, emphasizing the need for completion of nursing education and passing a standardized examination. Similarly, the State 11213 form requires completion of specialized education and practical experience, particularly for those aiming to become Qualified Medication Aides.

• Certified Nursing Assistant (CNA) Certification Renewal Form: This form shares similarities with the State 17213, especially in the sections that require proof of continued education and practical experience. CNAs must often submit documentation of ongoing professional development, just as applicants of the State 17213 form must provide evidence of completed classroom and practical training. Both documents underscore the importance of maintaining competent practice in healthcare settings, ensuring that individuals are up-to-date with their skills and knowledge.

• Application for Professional Rescertification: Many professions within healthcare require periodic recertification to ensure that professionals remain qualified to practice, reflecting a principle similar to the State 17213 form's purpose. These applications often require the applicant to list recent educational courses or seminars attended, much like the section on the State 17213 form that details course information and practicum completion. Additionally, both types of documents frequently incorporate sections for the verification of the applicant's information by a supervising professional, ensuring that all stated qualifications are legitimate and current.

When filling out the State Form 17213 for the Indiana State Department of Health, there are several important steps and precautions to keep in mind. Here are some do's and don'ts to ensure the process goes smoothly:

Do's:

• Fill out your legal name clearly and accurately as it appears on official documents.
• Include your complete and current address, along with your phone number, ensuring all contact information is up-to-date.
• Disclose your Social Security Number if you're comfortable; remember, it's voluntary and for identification purposes.
• Ensure the RN Instructor’s and Nurse Supervisor’s signatures are in red ink, as specified in the form instructions.
• Verify the accuracy of the information you provide, especially in the Applicant Verification Section.
• Attach all required documents, including your high school diploma, GED, or transcript, and the original documentation of practicum.
• Include the correct testing fee of $60.00 with a money order, as personal checks are not accepted.

Don'ts:

• Don’t use abbreviations when filling out the Facility/School Name in the Course Information sections.
• Avoid leaving any sections blank. If a section doesn't apply, consider writing 'N/A' instead of skipping it.
• Do not falsify any information. This could lead to the denial or revocation of qualifications.
• Refrain from sending personal checks for the testing fee. Only money orders are accepted to avoid processing issues.
• Do not sign in black or blue ink if a red ink signature is required by an RN Instructor or Nurse Supervisor.
• Avoid missing the deadline for application submission to ensure your application is processed in time for your desired test date.
• Don’t forget to review the entire form before sending it. Missing information or documents can delay processing.

By following these do's and don'ts, you can complete the State Form 17213 effectively, ensuring a smoother process for your qualified medication aide test application.

Understanding the State 17213 Form, a crucial application in Indiana for those aspiring to become Qualified Medication Aides, is vital. Several misconceptions surround this form, leading to confusion and errors in application. To clarify, below are ten common misconceptions about the State 17213 form:

• Only for Indiana Residents: It's a common belief that only Indiana residents can apply using this form. However, it caters to individuals who wish to work in Indiana, including those completing qualifications from out-of-state or internationally.
• Social Security Number Requirement: Potential applicants often misunderstand the language regarding the Social Security Number (SSN) disclosure. While the form requests an SSN under the Privacy Notice, providing it is voluntary and not a mandatory step for application completion.
• Red Ink Signature Exclusivity: The stipulation that RN instructors and nurse supervisors must sign in red ink is frequently overlooked or misunderstood. This unique requirement ensures that original documents are easily distinguished from copies.
• Form Complexity: Some might perceive the State 17213 form as overly complex. In reality, it is straightforward when approached systematically, clearly dividing into relevant sections for applicant information, course details, and verification.
• Classroom and Practicum Hours Flexibility: There's a misconception that the classroom education and practicum hours are flexible. The form outlines strict requirements of 60 hours classroom and 40 hours practicum to ensure comprehensive training.
• Immediate Test Eligibility Post Completion: Completing the application doesn't immediately qualify an applicant for the test. Approval from the ISDH and compliance with all documentation and fees are prerequisites for test eligibility.
• Digital Submission Option: As of the latest information, the form and accompanying documents need to be mailed physically. The misconception that these can be submitted digitally can result in processing delays.
• Acceptance of Personal Checks: The instructions specify that the testing fee must be paid via money order, yet some believe personal checks are accepted. Adhering to the stated payment method is crucial to avoid application rejection.
• Unlimited Testing Attempts: The form provides sections for documenting up to three test attempts, which may lead some to think there is no limitation on the number of attempts. Each application and retest may have specific requirements and limitations not explicitly stated on this form.
• Privacy Notice Misinterpretation: Applicants often worry about the security of their personal information. The Privacy Notice provides reassurance that the information collected is for the legitimate purpose of processing the application under state law, with disclosure being voluntary.

Understanding these misconceptions is the first step towards a successful application process. Applicants are encouraged to read the details of the State 17213 form carefully and to seek clarification when necessary to ensure a smooth path to becoming a Qualified Medication Aide.

Filling out the State 17213 form is an important step for becoming a Qualified Medication Aide (QMA) in Indiana. To ensure the process is smooth and compliant, here are some key takeaways to keep in mind:

• Make sure all information entered in the Applicant Information section is accurate and matches your legal documents, especially your LEGAL Name, Birth Date, and Social Security Number (SSN).
• The Privacy Notice clarifies that your SSN is requested for identification purposes under specific Indiana Code, indicating that providing it is voluntary but necessary for the application process.
• For the Course Information sections, both classroom education and practicum pieces require verification by an instructor and a nurse supervisor, respectively. Pay attention that the RN Instructor's signature must be in red ink, signifying its authenticity and importance.
• Documenting the completion of 60 hours of classroom education and 40 hours of practical experience is crucial. These hours are a prerequisite for application and must be verified by the respective instructor and supervisor.
• It is essential for the instructor and nurse supervisor to include their license numbers next to their signatures for the application to be processed, validating the credibility of the training received.
• Applicants must sign the Applicant Verification section, declaring that the information provided is true and accurate to the best of their knowledge. Falsification of this document can lead to denial or revocation of qualification.
• When compiling documents for the Documentation section, ensure inclusion of all the required items listed, such as the original application, proof of education, documentation of practicum, and the applicable fee. Remember, only a money order is accepted for the testing fee.
• Lastly, when sending your application and accompanying documents to Professional Resources, verify that everything is complete and correctly organized to avoid delays in the application process.

By closely following these guidelines, applicants can navigate the process of completing and submitting the State 17213 form more efficiently, bringing them one step closer to becoming a Qualified Medication Aide in Indiana.