Athletic Trainer Renewal/Reinstatement Application

Transcription

1 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT Athletic Trainer renewalclerk@sec.state.vt.us Current Expiration 09/30/2016 Athletic Trainer Renewal/Reinstatement Application Renewal Period Covering 10/01/2016 through 09/30/2018 Renewal Application Fee $ n Refundable Processing Fee Checks Payable to: Vermont Secretary of State You Must Complete The Information Below: For Office Use Only License #: ---- Name: Address: City/State/ZIP: Country: Directions: To renew you must enclose a check or money order in the amount indicated, payable in US funds from a bank with a United States affiliate to Vermont Secretary of State. The renewal fee is non-refundable. If the completed renewal application, along with all supporting documentation, is not received in the Office by the expiration date, you will be required to pay an additional penalty in addition to the renewal fee. Call the Office for a calculation of the penalty before submitting this renewal application. Reminder: You may not practice your licensed profession without an active license. Faxes not accepted. Has your name changed since you last renewed, or were originally licensed? (Circle One) If, you must attach a copy of your marriage license, civil union license or section of divorce decree granting you the authority to change your name. Section A: Demographic Information If your mailing address has changed, indicate your new address in the box to the right. te: It is unprofessional conduct for a licensee to fail to notify the Secretary of State s Office of a change of name or address within thirty (30) days (3 V.S.A. 129a(a)(14)). P.O. Box Street/Apt # City/State/Zip Country Street/Apt # If your 911 address has changed, indicate your new address in the box to the right. Suite/Department/Floor City/State/Zip Phone: ( ) - Cell Phone: ( ) - Address: Date of Birth (MM/DD/YYYY) Gender: (Circle One) / / Male Female

2 Section B: Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license. Name (print): License Number: 2

3 Section C: Vermont Mandatory Credential and Fitness Questions Please circle or for each of these questions. If the answer is, follow the provided instructions. Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) taken any disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Since your license was last renewed (or since it was issued if within the last two years): Have you surrendered a license, certificate, or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Since your license was last renewed (or since it was issued if within the last two years): Have you been convicted of a crime other than a minor traffic violation? Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. If, you must provide a detailed written explanation and attach the official court documents, (i.e., the affidavit of probable cause, the information and/or the docket report). Do you have any criminal charges pending against you in Vermont or any other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation. Name (print): License Number: 3

4 Section D: Continuing Education Requirement You are not required to send any supporting documentation with this form if you renew by the license expiration date. The Office of Professional Regulation reserves the right to verify information submitted by applicants for renewal and conducts a random audit of CE for each profession. You must retain all documentation for seven years after completion of the program/course. Please complete the Continuing Education Record on the next page. If you are renewing more than 30 days late, you must submit all CE documents with your completed renewal form. Athletic Trainer Administrative Rule 3.1 (B) Renewing Licenses Biennially B. As a condition of renewal, the licensee must show proof of current certification by the BOC. Do you hold a current certificate from the BOC (Board of Certification)? Section E: Expired Renewal If this is a late renewal, have you been practicing in Vermont since your license expired? If, please attach a description of the extent of your practice since your license expired. N/A Section F: Affirmation Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for renewal or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant Signature Date (MM/DD/YYYY) Print Name: License # ---- Name (print): License Number: 4

5 Office of Professional Regulation Vermont Secretary of State Attn: Renewal Clerk 89 Main St. 3 rd Floor Montpelier, VT Phone: (802) Fax: (802) Vermont Office of Professional Regulation Survey (optional) 2016 Renewal License #: Name: Would you be willing to serve as a Board/Advisor member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 2. Would you be willing to serve as an Ad Hoc member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 3. Would you be willing to serve as an Expert Witness for a licensing case(s) associated with your profession? If you answered to the question above, what is your area of expertise? Name (print): License Number: 5

6 Vermont Department of Health 2016 Census of Athletic Trainers The Department of Health has been conducting a census of selected health care providers every two years as part of their relicensing since This has allowed us to monitor changes in Vermont s health care workforce. These findings have been usead in the State Health Plan, the Health Resources Allocation Plan, and the designation of underserved areas. In 2013, the Legislature enacted a law to make work force data collection mandatory for all health care professions at license renewal as a necessary part of health care reform and planning for our health care future. This information is very important if we are to accurately assess the current situation and predict the need for health care providers in Vermont. We would like to thank you for your participation in this census. Identification 1) First Name 2) Middle Name (if any) 3) Last Name Demographics 5) Date of birth (M/D/YYYY) 6) Sex ( ) Male ( ) Female 7) How would you classify your race (check all that apply): [ ] American Indian or Alaska Native [ ] Black or African American [ ] White [ ] Asian [ ] Native Hawaiian or other Pacific Islander [ ] Other - please specify: [ ] Prefer not to answer 8) Are you Hispanic, Latino/a, or of Spanish origin? [ ] [ ], Mexican, Mexican American, Chicano/a [ ], Puerto Rican [ ], Cuban [ ], another Hispanic, Latino/a, or of Spanish origin [ ] Prefer not to answer 4) Vermont Athletic Trainer License #

7 Training 9) What was your entry level athletic trainer degree, certificate, or training? ( ) Apprenticeship ( ) NATA Curriculum & Certification Exam ( ) CAATE or CAAHEP program at Bachelor s level ( ) CAATE or CAAHEP program at Master s level ( ) Other (specify): 10) In what year did you complete your entry level Athletic Trainer education? 11) Please enter the two letter code for the state where you completed your entry level Athletic Trainer education: (Use 2-letter abbreviations for states; CC for Canada, XX for other foreign countries) 12) If completed outside the U.S. or Canada, please specify country: 13) Have you completed a post-professional residency program in Athletic Training? ( ) ( ) 14) Have you completed a post-professional degree program in Athletic Training? ( ) ( ) 15) Do you hold current credentials (license, certification, educational degree) in any of the following fields: [ ] EMT [ ] Nursing [ ] Orthotics [ ] Personal Trainer [ ] Physical Therapy [ ] Physician Assistant [ ] Prosthetics [ ] Massage therapy [ ] Strength & Condition Specialist [ ] Teaching / Education [ ] Other (please specify): 16) Please indicate the highest level of education (in any field) that you have completed as of today: ( ) Associate Degree (AA, AS, etc) ( ) Bachelor s Degree (BA, BS, etc) ( ) Master's Degree (MA, MEd, MS, etc) ( ) Doctorate (PhD, EdD, DAT, MD, etc) ( ) Other (specify):

8 17) Do you have a National Provider Identification (NPI) number? If yes, please write in the NPI number. ( ) ( ) : 18) Do you have a NATA BOC number? If yes, please write in the BOC number. ( ) ( ) : 19) Do you have a NATA membership number? If yes, please write in the NATA membership number. ( ) ( ) : 20) In what year did you obtain your first Athletic Trainer certification? 21) In what year did you obtain your first Athletic Trainer license? 22) In what state(s) (other than Vermont) do you hold an active Athletic Trainer license? - State (postal) abbreviation(s) State 1: State 2: State 3: 23) In what year did you start practicing (anywhere) as a licensed Athletic Trainer? (if never, leave blank) 24) In what year did you start practicing as a licensed Athletic Trainer in Vermont? (if never, leave blank) Currently active 25) What is your employment status? (select all that apply) [ ] Working IN VERMONT in a position that requires an Athletic Trainer license [ ] Working outside Vermont in a position that requires an Athletic Trainer license [ ] Actively working in a different field [ ] t currently working [ ] Retired 26) If not working in Vermont now, do you plan to start (or resume) working as an athletic trainer in Vermont within the next 12 months? ( ) ( ) If you do not currently provide direct client care in Vermont, please stop here and return this census form. Thank you!

9 26) What are your plans for the next 12 months regarding your work as an Athletic Trainer in Vermont? ( ) Continue as you are ( ) Increase hours ( ) Decrease hours ( ) Seek work in another field ( ) Retire ( ) Unknown 32) During how many weeks in a year do you work at this site as an Athletic Trainer? (48 weeks per year is considered "year-round".) 33) Please indicate the average number of hours spent per working week at this site providing direct Client/Patient Care: First Vermont practice site (your principal practice / employment site, providing direct client/patient care as an Athletic Trainer in Vermont): 28) Vermont town name (not a mailing address): 29) Zip code of practice location: 30) Practice name: 34) Choose the one description that best fits your practice setting at this site: ( ) Interscholastic ( ) Intercollegiate ( ) Professional athletics organization or facility ( ) Health and Wellness Facility ( ) Rehabilitation facility ( ) Private practice ( ) Other - please specify: 31) Street Address:

10 35) Please tell us about time spent on activities other than direct client/patient care at this site: Hours per working week in administration at this site: Hours per working week in supervision at this site: Hours per working week in teaching at this site: Hours per working week in research at this site: Hours per working week in other activities (not mentioned above) at this site: Please describe the "other activities", if any: 40) During how many weeks in a year do you work at this site as an Athletic Trainer? (48 weeks per year is considered "year-round".) 41) Please indicate the average number of hours spent per working week at this site providing direct Client/Patient Care: Second Vermont practice site: (if none, leave this section blank) 36) Vermont town name (not a mailing address): 37) Zip code: 38) Practice name: 42) Choose the one description that best fits your practice setting at this site: ( ) Interscholastic ( ) Intercollegiate ( ) Professional athletics organization or facility ( ) Health and Wellness Facility ( ) Rehabilitation facility ( ) Private practice ( ) Other - please specify: 39) Street Address:

11 43) Please tell us about time spent on activities other than direct client/patient care at this site: Hours per working week in administration at this site: Hours per working week in supervision at this site: Hours per working week in teaching at this site: Hours per working week in research at this site: Hours per working week in other activities (not mentioned above) at this site: Please describe the "other activities", if any: Final comments 46) Thank you. If there is anything else you want to tell us about your practice, or this census, please enter it here: Additional Vermont practice sites 44) Do you have more than two practice sites in Vermont? ( ) yes ( ) no 45) If yes, please describe your work at additional sites beyond the three you entered above, briefly, including locations, specialties and hours: