Cost: $55 per person.

ABOUT THIS COURSE

The primary purpose of the course is to teach the principles and procedures of safe and accurate medication administration and the accompanying documentation. This is a basic learning course. Employers are responsible for additional training.

FOR STUDY MATERIALS and MORE INFORMATION:

http://www.cdphe.state.co.us/hf/medadmin/index.html

 TO REGISTER FOR THIS QMAP CLASS YOU MUST DO THESE THREE THINGS:

1. PAYMENT

Payment must be received before the class. Please include your payment of $55 per person with the two documents listed below.

CDPHE requires Business Check or Money Order – no personal checks, cash or credit cards.
Make check or Money Order payable to:

The Colorado Dept. of Public Health

2. IDENTIFICATION NEEDED

Please bring to the class a form of photo-identification. And send a photocopy of your id to ‘Solutions for Occupational Safety’ P.O. Box 258, Black Hawk, CO 80422 in advance of the class. This will be sent to the CDPHE for verification.

These are the acceptable forms of identification:
· Colorado driver’s license or non-driver id
· Federal, State or Local government id
· Military id
· Tribal id
· Student id
· Passport

3. DISCLOSURE FORM

· When you send in the copy of your identification please include a completed printout of the
‘Medication Administration Class Disclosure Form’
Please follow the link to a pdf of the Form
Or
Cut-and-paste the Form below into your word processor, print out, complete and send to Solutions for Occupational Safety.

After you satisfactorily complete the class this form will go to your employer

STATE of COLORADO CERTIFICATION REQUIREMENTS

WRITTEN EXAM

· Students must pass the written exam with a score of at least 90% before they take the practicum.

PRACTICUM

· Practicum is a hands-on test. Students must demonstrate competency in all items listed on the Practicum requirement sheet, Students must pass with 100%

================================

Please complete this form and mail in to SOS before the class. Include the CLASS DATE YOU WANT at the bottom of the Form.

Please complete this form and mail in before the class. Include the CLASS DATE you want at the bottom of the Form
Medication Administration Class Disclosure Form
Please print clearly – completion of this section and the student signature is MANDATORY.

Student Name: ____________________________________________________________
Student complete mailing address: ____________________________________________________________
____________________________________________________________
Student phone number: ______________________

Student email: ______________________________________________

SSN: (Last 6 digits only): XXX-______-________

1. I have been informed of the objectives for this course.
2. I have been informed by the instructor that successful completion of this course permits me to administer mediations only in these settings:

A. Assisted living residences
B. Alternative care facilities
C. Secure residential treatment centers
D. State certified adult day care programs

• Programs regulated by the Department of Human Services, have their own QMAP program specifically designed for that population type(S).
• Programs regulated by the Department of Corrections, have their own QMAP program specifically designed for that population type.

3. I understand that successful completion of this class does not certify or license me to administer medications.
Rather, this course is designed to qualify me to perform the tasks taught in this course.
4. I understand that this course does not authorize me to assess, evaluate or use judgment in regard to a client’s physical condition or medication utilization. Successful completion of this course does not authorize me to give injections or perform any other invasive procedures.
5. I understand that I may be required to retake an approved medication administration course and competency evaluation if the Colorado Department of Public Health and Environment or other authorized agency determines the need for such training.
6. I understand that I may be a qualified manager in my facility and as such must retake an approved test every four years, if supervising the filling of Medication Reminder Boxes.
7. I declare that I have never had a professional license to practice nursing, pharmacy or medicine revoked, suspended or had any actions taken on my professional license in any state for reasons related to the administration of medications.
8. I understand that I if I take the entire QMAP course and fail the exams I can retest for an additional fee. If I fail twice I must wait 6 months before taking the class and exams again.
9. I understand that if I choose to take the “Exams only” and fail that I must take the entire course for an additional fee.
10. I understand I will receive a “Letter of Completion” if I successfully pass the exams and CDPHE will mail my official Recognition of Completion document within 90 days.
11. I understand that the Recognition of Completion document signifying satisfactory completion of this course is to be retained by me and that a duplicate is not available from the instructor or the Colorado Department of Public Health and Environment.

CLASS DATE YOU WANT: _____________________________________

Student Signature: ___________________________________________________

Date:___________________

Instructor Signature: __________________________________

Date: ___________________

revised May 2010 CDPHE

Please print clearly – completion of this section and the student signature is MANDATORY.

Medication Administration Class Disclosure Form