QMA Application

Personal Information

Name(Required)
Address(Required)
MM slash DD slash YYYY
Have you previously been enrolled in a course at SWIHSA?
Have you previously been a QMA?

You must meet the following requirements to participate in this program:

Are you at least 18 years of age or older?(Required)
(If no, you will need parental consent to complete this program.)
Do you have a high school diploma or GED?(Required)
Have you worked as a CNA for a minimum of 1000 hours within the last 24 months?(Required)

Do you currently work in a nursing facility?
How will you be paying for the class?
Cost: $1,400.00
How did you hear about the SWIHSA program?

Applicant's Statement

The Indiana Department of State says if you have anything on your criminal history that is listed below you may not be able to attend the CNA Program. Please indicate if you have been convicted of the following
A sex crime(Required)
Exploitation of an endangered adult(Required)
Failure to report battery, neglect, or exploitation of an endangered adult(Required)
Theft within the previous five (5) years(Required)
Murder(Required)
Voluntary manslaughter(Required)
Involuntary manslaughter within the previous five (5) years(Required)
Felony battery within the previous five (5) years(Required)
A felony offense relating to controlled substances within the previous five (5) years(Required)
Abused, neglected, or mistreated a patient or misappropriated a patient’s property; and had a finding entered into the state nurse aide registry(Required)
Are you a person who knowingly or intentionally applies for a job as a nurse aide or other unlicensed employee at:(Required)
(1) a health care facility; or (2) an entity in the business of contracting to provide nurse aides or other unlicensed employees for a health care facility; after a conviction of one (1) or more of the offenses listed above?

The Indiana State Department of Health requires that you must be able to pass a drug screen. Any samples provided that do not pass Deaconess Comp Centers criteria could automatically disqualify you from this program.(Required)
Please inicate that you understand the above statement and are able to pass a drug screen provided by deaconess comp center.

By submitting this application, I acknowledge that I have answered the above questions to the best of my knowledge.

This field is for validation purposes and should be left unchanged.