Section 5123-6-06 - Qualifications, training, and certification of developmental disabilities personnel who perform health-related activities and administer prescribed medication(A) Purpose This rule sets forth eligibility and requirements for three types of training programs and resulting certification held by developmental disabilities personnel:
(1) Health-related activities and prescribed medication administration;(2) Prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation; and(3) Administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation.(B) Eligibility to take a training program required to perform health-related activities and administer prescribed medication(1) To be eligible to take a training program described in paragraph (C) of this rule, developmental disabilities personnel will: (a) Be at least eighteen years of age;(b) Hold a high school diploma or general education development certificate; and(c) Be able to read, write, and understand English at a level sufficient to comply with all requirements set forth in administrative rules governing the services provided.(2) Prior to permitting developmental disabilities personnel to enroll in a training program described in paragraph (C) of this rule, the registered nurse trainer will, as applicable:(a) Secure an attestation from the employer of developmental disabilities personnel that the developmental disabilities personnel has been subject to a completed background check conducted in accordance with rule 5123-2-02 of the Administrative Code with results received; or(b) Verify that the developmental disabilities personnel holds independent provider certification issued by the department.(C) Training programs for developmental disabilities personnel(1) Health-related activities and prescribed medication administration training program(a) A health-related activities and prescribed medication administration training program provided pursuant to this rule, to prepare developmental disabilities personnel to perform health-related activities, administer oral prescribed medication, administer topical prescribed medication, administer topical over-the-counter musculoskeletal medication, and administer oxygen and metered dose inhaled medication, will be at a minimum a fourteen-hour course; one hour equals sixty minutes of classroom instruction. Relevant agency-specific and/or facility-specific material may be added to the department-approved curriculum described in paragraph (C)(1)(c) of this rule only with additional corresponding classroom instruction time beyond the fourteen-hour course.(b) The department may authorize a registered nurse trainer to provide a portion of the health-related activities and prescribed medication administration training program by audio-visual distance learning. The department's authorization will be based upon review and approval of a training program syllabus and supporting documentation submitted by the registered nurse trainer that demonstrate the audio-visual distance learning meets the following requirements: (i) The registered nurse trainer will develop a syllabus that:(a) Outlines specific content and number of hours of the training program to be conducted by audio-visual distance learning and by in-person classroom instruction;(b) Describes methods for providing students with training manuals and materials;(c) Reflects incorporation of evidence-based principles of adult learning in the instructional design;(d) Includes interactive learning activities to achieve student engagement with the registered nurse trainer and other students;(e) Describes methods to be used by the registered nurse trainer to verify student comprehension of information and skills;(f) Sets forth that a student will complete the return demonstration of proficiency, including transcription, described in paragraph (E)(1)(c) of this rule, the written examination described in paragraph (E)(1)(d) of this rule, and the evaluation of the training program described in paragraph (E)(1)(e) of this rule during the in-person classroom instruction portion of the training program; and(g) Provides sufficient detail to demonstrate how the requirements set forth in paragraphs (C)(1)(b)(ii) and (C)(1)(b)(iii) of this rule will be met.(ii) Audio-visual distance learning will be conducted using conferencing software that provides for:(a) Two-way audio and video interactive capability by all participants;(b) All participants to see one another including each participant's face and upper body from the desktop and above;(c) The registered nurse trainer to share and present materials on screen;(d) A private chat feature that enables a student to chat with the registered nurse trainer and ask questions if muted;(e) Authenticated log-on by participants;(f) An enabled waiting room so that the registered nurse trainer controls admission of students;(g) The registered nurse trainer to track a student's attendance and presence in the meeting room;(h) Prevention of anyone other than the registered nurse trainer from recording the training program; and(i) The registered nurse trainer to control and disable a student's audio and video capability and remove a student when necessary.(iii) The registered nurse trainer is responsible for ensuring:(a) A student's video monitor is large enough to allow clear visualization of the registered nurse trainer, the presented materials, and demonstrations. Neither a student nor the registered nurse trainer is permitted to participate in the audio-visual distance learning via a hand-held cellular telephone.(b) The class size is such that the registered nurse trainer clearly visualizes each student on the registered nurse trainer's video monitor.(c) A student experiencing technical difficulties with the audiovisual conferencing software is not considered in attendance for that portion of the training program.(c) The health-related activities and prescribed medication administration training program will address:(i) A review of an individual's right to self-administer medication, self-administer medication with assistance, and participate in steps of medication administration when not able to self-administer medication or self-administer medication with assistance.(ii) Concepts of person-centered planning relevant to an individual's consent or declination of prescribed medication.(iii) Universal precautions for infection control. The registered nurse trainer may waive the universal precautions for infection control instruction material and instruction time of the program if the developmental disabilities personnel can document training on that topic within the previous year.(iv) A review of applicable federal and state drug laws and rules.(v) Information and instruction on the concepts underlying each step for correctly administering oral prescribed medication, administering topical prescribed medication, administering topical over-the-counter musculoskeletal medication, and administering oxygen and metered dose inhaled medication according to current standards of safe practice, procedures, and techniques.(vi) Information and instruction to train the developmental disabilities personnel to administer the right medication, at the right dose, to the right individual, by the right route, at the right time and with the right documentation.(vii) Written step-by-step directions on how to administer oral prescribed medication, administer topical prescribed medication, administer topical over-the-counter musculoskeletal medication, and administer oxygen and metered dose inhaled medication. (viii) Instruction in safe storage and transport of oxygen.(ix) Instruction in taking vital signs (i.e., temperature, pulse, respiration, and blood pressure).(x) Instruction in application of clean dressings that do not require health assessment.(xi) Instruction in basic measurement of bodily intake and output.(xii) Instruction in oral suctioning.(xiii) Instruction in use of glucometers.(xiv) Instruction in external urinary catheter care.(xv) Instruction in emptying and replacing ostomy bags.(xvi) Instruction in application of prescribed compression hosiery.(xvii) Instruction in collection of specimens by noninvasive means.(xviii) Instruction in the use of pulse oximetry to accurately record an individual's oxygen saturation as prescribed by a licensed health professional authorized to prescribe drugs.(xix) Instruction in the use of continuous positive airway pressure machines, including biphasic positive airway pressure machines, for the intermittent delivery of continuous positive airway pressure to treat obstructive sleep apnea or sleep-related hypoventilation as prescribed by a licensed health professional authorized to prescribe drugs.(xx) Instruction in the application of percussion vests to promote airway secretion clearance as prescribed by a licensed health professional authorized to prescribe drugs.(xxi) Instruction in the use of cough assist devices and insufflators to promote the removal of airway secretions in those with respiratory muscle weakness as prescribed by a licensed health professional authorized to prescribe drugs.(xxii) Instruction in the use of metered dose inhaled medication administered by a hand-held dispenser and the use of an aerosol nebulizer to administer a pre-measured medication for the treatment of asthma or other respiratory condition as prescribed by a licensed health professional authorized to prescribe drugs.(xxiii) Information and instruction in responsibility of developmental disabilities personnel for following the step-by-step procedures for administration of all medication and performance of health-related activities and completing additional training before attempting any action for which the developmental disabilities personnel is not competent.(xxiv) Information and instruction in responsibility of developmental disabilities personnel for knowing the purpose of medication and health-related activities being performed or administered and facilitating the reporting of problems, including lack of effectiveness and potential side effects, to a healthcare professional.(xxv) Instruction in quality measures, including but not limited to, procedures for reporting and documenting medication/treatment errors that may occur when performing health-related activities, administering oral prescribed medication, administering topical prescribed medication, administering topical over-the-counter musculoskeletal medication, and administering oxygen and metered dose inhaled medication.(xxvi) Procedures to be followed in case of medication emergency including when, why, and how to contact the employer of developmental disabilities personnel or designee, a healthcare professional, or the supervising licensed nurse when medication is administered or a nursing task is performed pursuant to nursing delegation.(xxvii) Information about what developmental disabilities personnel may be authorized to perform with respect to administering oral prescribed medication, administering topical prescribed medication, administering topical over-the-counter musculoskeletal medication, or administering oxygen and metered dose inhaled medication.(xxviii) Limitations with respect to "as needed" (or "PRN") prescribed medication, which state that developmental disabilities personnel will not administer a prescribed medication ordered by a physician or other licensed health professional authorized to prescribe drugs when the prescribed medication is to be administered as needed, unless the order is written with specific parameters which preclude independent judgment.(xxix) Limitations with respect to over-the-counter medication which include the need for a prescription from a licensed health professional authorized to prescribe drugs to administer all over-the-counter medication not authorized for administration by developmental disabilities personnel pursuant to section 5123.42 of the Revised Code.(xxx) The requirement for specialized training pursuant to this rule for the administration of topical over-the-counter medication for the purpose of cleaning, protecting, or comforting the skin, hair, nails, teeth, or oral surfaces.(xxxi) Instruction in the use of topical over-the-counter musculoskeletal medication.(xxxii) Information about what developmental disabilities personnel are prohibited from administering, which includes but is not limited to: (a) An intramuscular injection;(b) An intravenous injection;(c) A subcutaneous injection, except a subcutaneous injection of insulin or prescribed medication for the treatment of metabolic glycemic disorders, provided the developmental disabilities personnel are trained and hold administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation certification in accordance with this rule and the subcutaneous injection of insulin or prescribed medication for the treatment of metabolic glycemic disorders is delegated to a specific person by a licensed nurse pursuant to section 5123.42 of the Revised Code and this chapter;(d) Any prescribed medication administered through a nasogastric tube or an unstable or unlabeled gastrostomy tube or an unstable or unlabeled jejunostomy tube; and(e) Any debriding agent used in the treatment of a skin condition or minor abrasion.(xxxiii) Instruction in the use of commercially packaged rectal diazepam gel for the treatment of epilepsy as prescribed by a licensed health professional authorized to prescribe drugs.(xxxiv) Instruction in the use of commercially packaged glucagon for the treatment of hypoglycemia as prescribed by a licensed health professional authorized to prescribe drugs. Teaching must be completed and nursing delegation must be in place prior to administration of glucagon.(xxxv) Instruction in potential drug reactions, including known side effects, interactions, and the proper course of action if a side effect occurs, and sources for prescribed medication information (such as pharmacist, physician, nurse, or poison control center).(xxxvi) The requirements for documentation of prescribed medication administered, missed, held, or declined to, by, or for each individual.(xxxvii) The definition of a medication/treatment error and requirements for documentation and notification of unusual incidents and major unusual incidents related to medication/treatment errors.(xxxviii) Information regarding the appropriate and secure storage and care of prescribed medication.(xxxix) Instruction that in settings where developmental disabilities personnel are administering prescribed medication, with or without nursing delegation, medication may be administered only from pharmacy-labeled or manufacturer-labeled containers and only by the person who prepared the dosage from those containers.(xl) Information and instruction about who may receive and who may transcribe physician orders and prescriptions on to a medication administration record or treatment administration record specific to each category pursuant to rule 5123-6-03 of the Administrative Code.(xli) Performance of a successful return demonstration for each route of prescribed medication administration in which developmental disabilities personnel are trained.(xlii) Performance of a successful return demonstration for each health-related activity in which developmental disabilities personnel are trained.(xliii) Information that health-related activities are performed only pursuant to nursing delegation except for individuals:(a) Receiving family support services or services from certified supported living providers, if the services are offered or provided pursuant to Chapter 5123. or Chapter 5126. of the Revised Code;(b) Receiving residential support services from certified home and community-based services providers, if the services are received in a community living arrangement that includes no more than four individuals;(c) Residing in a residential facility with five or fewer beds; or(d) Receiving adult day services in a setting where services are provided to sixteen or fewer individuals.(xliv) Information and instruction on the concepts underlying each step for performing health-related activities according to current standards of safe practice, including instruction in the correct and safe practices, procedures, and techniques for performing health-related activities.(xlv) Instruction in the usual parameters of health-related activities and instruction in the course of action to be taken when parameters of health-related activities are above or below those taught.(xlvi) Completion of written examination pursuant to paragraph (E)(1)(d) of this rule.(xlvii) Requirements for individual-specific training which will occur after certification and prior to administration of prescribed medication or performance of health-related activities. The employer of developmental disabilities personnel, the delegating nurse, or the county board will ensure that developmental disabilities personnel receive individual-specific training.(2) Prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation training program (a) A prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation training program provided pursuant to this rule to prepare developmental disabilities personnel to administer prescribed medication through stable labeled gastrostomy and jejunostomy tubes will be at a minimum a four-hour course and will be in addition to the health-related activities and prescribed medication administration training program described in paragraph (C)(1) of this rule; one hour equals sixty minutes of classroom instruction. Relevant agency-specific and/or facility-specific material may be added to the department-approved curriculum described in paragraph (C)(2)(b) of this rule only with additional corresponding classroom instruction time beyond the four-hour course. Developmental disabilities personnel will successfully complete the health-related activities and prescribed medication administration training program described in paragraph (C)(1) of this rule prior to participating in the prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation training program.(b) The prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation training program will address:(i) Correct and safe practices, procedures, and techniques for administering prescribed medication through stable labeled gastrostomy and jejunostomy tubes, including possible signs and symptoms of gastrostomy or jejunostomy tube malfunction or tube problems, complication or intolerance of prescribed medication by the individual, and appropriate response to a gastrostomy or jejunostomy tube that becomes dislodged.(ii) Requirements for documentation of prescribed medication administered, missed, held, or declined to, by, or for each individual through stable labeled gastrostomy or jejunostomy tube.(iii) Requirements for documentation and notification of prescribed medication errors through stable labeled gastrostomy or jejunostomy tube.(iv) Information regarding the proper storage, care, and preparation of prescribed medication to be administered through stable labeled gastrostomy or jejunostomy tube.(v) Information regarding the proper storage and care of gastrostomy and jejunostomy tubes.(vi) Requirements for nursing delegation of prescribed medication administration through stable labeled gastrostomy and jejunostomy tubes.(vii) Instruction that only the delegating nurse or a licensed nurse in coordination/communication with the delegating nurse will receive prescriptions for prescribed medication to be administered through stable labeled gastrostomy or jejunostomy tube and only the delegating nurse or a licensed nurse in coordination/communication with the delegating nurse will transcribe these prescriptions on to a medication administration record or treatment administration record.(viii) Performance of successful return demonstration of proficiency in administering prescribed medication through stable labeled gastrostomy and jejunostomy tubes.(ix) Completion of written examination pursuant to paragraph (E)(1)(d) of this rule.(x) Requirements for individual-specific training which will occur after certification and prior to administration of prescribed medication through stable labeled gastrostomy or jejunostomy tube. The delegating nurse is responsible for the individual-specific training.(3) Administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation training program(a) An administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation training program provided pursuant to this rule to prepare developmental disabilities personnel to administer insulin through subcutaneous injection, inhalation, and insulin pump and administer prescribed medication for the treatment of metabolic glycemic disorders through subcutaneous injection by nursing delegation will be a minimum a four-hour course and will be in addition to the health-related activities and prescribed medication administration training program described in paragraph (C)(1) of this rule; one hour equals sixty minutes of classroom instruction. Relevant agency-specific and/or facility-specific material may be added to the department-approved curriculum described in paragraph (C)(3)(b) of this rule only with additional corresponding classroom instruction time beyond the four-hour course. Developmental disabilities personnel will successfully complete the health-related activities and prescribed medication administration training program described in paragraph (C)(1) of this rule prior to participating in the administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation training program.(b) The administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation training program will address:(i) Information on the basic pathophysiology of metabolic glycemic disorders.(ii) Correct and safe practices, procedures, and techniques for administering insulin and subcutaneous injections, possible signs and symptoms of subcutaneous injection complication, and instruction in safe handling and disposal of sharps.(iii) The requirements for documentation of subcutaneous injections administered, missed, held, or declined to, by, or for each individual.(iv) Requirements for documentation and notification of prescribed medication errors and subcutaneous injection errors.(v) Information regarding the proper storage, care, and preparation of insulin or prescribed medication for treatment of metabolic glycemic disorders to be administered by subcutaneous injection.(vi) Signs and symptoms of hypoglycemia and hyperglycemia and procedure for intervention and notification of nurse, physician, or emergency medical services.(vii) Instruction in the use of commercially packaged glucagon for the treatment of hypoglycemia as prescribed by a licensed health professional authorized to prescribe drugs. Teaching must be completed and nursing delegation must be in place prior to administration of glucagon.(viii) Instruction that only the delegating nurse or a licensed nurse in coordination/communication with the delegating nurse will transcribe a prescription for insulin or prescribed medication for treatment of metabolic glycemic disorders on to a medication administration record.(ix) Performance of successful return demonstration of proficiency in administering insulin and subcutaneous injections.(x) Completion of written examination pursuant to paragraph (E)(1)(d) of this rule.(xi) Requirements for nursing delegation of administration of insulin through subcutaneous injection, inhalation, and insulin pump and administration of prescribed medication for the treatment of metabolic glycemic disorders through subcutaneous injection.(xii) Requirements for individual-specific training which will occur after certification and prior to administration of insulin through subcutaneous injection, inhalation, and insulin pump and administration of prescribed medication for the treatment of metabolic glycemic disorders through subcutaneous injection. The delegating nurse is responsible for the individual-specific training.(D) Requirements for training programs(1) The health-related activities and prescribed medication administration training program, the prescribed medication administration through gastrostomy or jejunostomy tube by nursing delegation training program, and the administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation training program will be planned, developed, and delivered by a registered nurse trainer certified by the department in accordance with rule 5123-6-04 of the Administrative Code. The registered nurse trainer will ensure that training programs are conducted in accordance with requirements set forth in this chapter.(2) A registered nurse trainer will use only a department-approved curriculum for the health-related activities and prescribed medication administration training program, the prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation training program, or the administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation training program.(3) A registered nurse trainer will personally conduct the majority of a training program but may utilize other licensed health professionals to assist with conducting the training program as long as the other licensed health professionals have received instruction on the material and are acting within their professional scope of practice as outlined in the Revised Code.(E) Initial certification of developmental disabilities personnel (1) To receive initial certification in health-related activities and prescribed medication administration, prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation, or administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation, developmental disabilities personnel will:(a) Attend the entire applicable training program.(b) Actively participate in the training program class discussions and activities.(c) Successfully perform a return demonstration of proficiency.(d) Complete the closed book final written examination for the training program with a score of at least eighty per cent. Developmental disabilities personnel scoring less than eighty per cent on the final written examination will retake the training program in its entirety to be eligible to retake the final written examination. The final written examination developed and maintained by the department will be the only final written examination used.(e) Complete and submit to the registered nurse trainer the evaluation of the training program.(2) Certification in health-related activities and prescribed medication administration is a prerequisite for certification in prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation or certification in administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation.(3) The registered nurse trainer will ensure developmental disabilities personnel meet all requirements for initial certification before indicating so in the medication administration information system database.(F) Maintenance of developmental disabilities personnel certification (1) To maintain certification in health-related activities and prescribed medication administration, prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation, or administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation, developmental disabilities personnel will annually complete continuing education that will enhance the role of developmental disabilities personnel who have completed the training program as determined by the registered nurse trainer. Developmental disabilities personnel will provide documentation of completion of the required continuing education to the registered nurse trainer. (a) To maintain certification in health-related activities and prescribed medication administration, developmental disabilities personnel will annually complete at least two hours of continuing education that relates to the information taught in the health-related activities and prescribed medication administration training program (as determined by the registered nurse trainer) and perform a successful return demonstration of skills.(b) To maintain certification in prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation, developmental disabilities personnel will annually complete at least one hour of continuing education that relates to the information taught in the prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation training program (as determined by the registered nurse trainer) and perform a successful return demonstration of skills. The continuing education required in this paragraph is in addition to the two hours of continuing education required for health-related activities and prescribed medication administration certification and, if applicable, the one hour of continuing education required for administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation certification.(c) To maintain certification in administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation, the developmental disabilities personnel will annually complete at least one hour of continuing education that relates to the information taught in the administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation training program (as determined by the registered nurse trainer) and perform a successful return demonstration of skills. The continuing education required in this paragraph is in addition to the two hours of continuing education required for health-related activities and prescribed medication administration certification and, if applicable, the one hour of continuing education required for prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation certification.(2) Training in cardiopulmonary resuscitation, first aid, activation of a vagus nerve stimulator, use of an epinephrine auto-injector, administration of topical over-the-counter medication, or universal precautions for infection control will not count toward continuing education required by paragraph (F)(1)(a), (F)(1)(b), or (F)(1)(c) of this rule.(3) Maintaining certification in health-related activities and prescribed medication administration is required to maintain certification in prescribed medication administration through gastrostomy and jejunostomy tube by nursing delegation and certification in administration of insulin and medication for the treatment of metabolic glycemic disorders by nursing delegation.(4) When developmental disabilities personnel fail to complete the required continuing education and return demonstration of skills by the annual certification expiration date, the certification of the developmental disabilities personnel will be temporarily inactive for a maximum period of sixty calendar days, during which time the developmental disabilities personnel will complete the required continuing education and return demonstration of skills. If the developmental disabilities personnel fail to complete the required continuing education and return demonstration of skills within the sixty-day suspension period, the developmental disabilities personnel will be required to repeat each training program in its entirety to become recertified.(5) While the certification of developmental disabilities personnel is temporarily inactive in accordance with paragraph (F)(4) of this rule, the developmental disabilities personnel will not:(a) Perform health-related activities;(b) Administer oral prescribed medication;(c) Administer topical prescribed medication;(d) Administer topical over-the-counter musculoskeletal medication;(e) Administer oxygen or metered dose inhaled medication;(f) Administer prescribed medication through gastrostomy or jejunostomy tubes;(g) Receive nursing delegation to administer prescribed medication through gastrostomy or jejunostomy tubes;(h) Administer prescribed insulin through subcutaneous injection, inhalation, or insulin pump;(i) Receive nursing delegation to administer prescribed insulin through subcutaneous injection, inhalation, or insulin pump;(j) Administer prescribed medication for the treatment of metabolic glycemic disorders through subcutaneous injection; or(k) Receive nursing delegation to administer prescribed medication for the treatment of metabolic glycemic disorders through subcutaneous injection.(6) The registered nurse trainer will ensure developmental disabilities personnel meet all requirements for renewal certification before indicating so in the medication administration information system database.(G) For adequate reasons and when requested in writing, the director may waive a condition or specific requirement of this rule. Approval to waive a condition or specific requirement will not be contrary to the rights, health, or safety of individuals served. The decision to grant or deny a rule waiver is not subject to appeal.(H) The standards established by the Ohio board of nursing pursuant to Chapter 4723-13 of the Administrative Code will apply when an unlicensed person is performing delegable nursing tasks that are not defined as health-related activities.Ohio Admin. Code 5123-6-06
Effective: 1/14/2024
Five Year Review (FYR) Dates: 10/30/2023 and 01/14/2029
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.42, 5123.43, 5123.45, 5123.46
Rule Amplifies: 5123.04, 5123.41 to 5123.47
Prior Effective Dates: 09/30/1993 (Emer.), 12/29/1993, 05/16/1994 (Emer.), 08/06/1994, 06/30/1995, 02/14/2000, 10/22/2003 (Emer.), 01/08/2004, 06/01/2016, 11/06/2017, 01/14/2021