Free 48318 - Indiana

QUALIFIED MENTAL RETARDATION PROFESSIONAL (QMRP)

To: From:

All MR/DD Providers MR/DD Program Directors Division of Long Term Care Regulation 483.430 (a)

Re:

Please provide the following information for each facility/home and give this form to the surveyor at the time of your exit conference. Provider/Agency Address-Home/Facility City , IN

Name of QMRP

Degree/License

Experience

Date Surveyor's Signature

, 20

State Form 48318 (R / 2-00) ICF/MR 3