Occupational Therapists / Occupation Therapy Assistant Renewal/Reinstatement Application

Transcription

1 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT Occupation Therapy Advisors renewalclerk@sec.state.vt.us Occupational Therapists / Occupation Therapy Assistant Renewal/Reinstatement Application Current Expiration 05/31/2016 Renewal Period Covering 06/01/2016 through 05/31/2018 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. Occupational Therapists and Occupational Therapy Assistants Administrative Rule 3.2 (a) Continuing Competence Requirements (a) "Continuing competence" means the direct involvement of an occupational therapist or occupational therapy assistant as a participant in activities promoting continuing competency in occupational therapy theory and practice. A total of 20 hours of continuing competence shall be earned in a two year renewal period. An occupational therapist or occupational therapy assistant who is renewing his or her license for the first time after initial licensure is subject to a 10 hour continuing competence requirement per full year of licensure. If the license has been held for one year or less, no continuing competence is required. If held more than one year but less than two years, ten hours is required. Continuing Education Requirement (Check the box that applies to your license.) Current NBCOT (National Board for Certification in Occupational Therapy) Certification. My Occupational Therapist/Occupational Therapy Assistant s license was first issued in Vermont prior to 06/01/2014 AND I have completed 20 hours of continuing education. (I do not hold a current NBCOT certification) My Occupational Therapist/Occupational Therapy Assistant s license was first issued in Vermont between 06/01/2014 and 05/31/2015 AND I have completed 10 hours of continuing education. My Occupational Therapist/Occupational Therapy Assistant s license was first issued in Vermont on or after 06/01/2015; therefore I do not have to complete continuing education for this renewal cycle (0 hours). I have NOT met the continuing education requirement (CE extensions may be granted in exceptional circumstances for good cause shown upon written request with a completed renewal form and fee submitted prior to the expiration date.) Name (print): License Number: 4

5 Itemize the education courses taken over the past two years (submit additional sheets if more space is needed) TITLE & CONTENT OF PROGRAM SPONSORING ORGANIZATION # OF CREDITS/HOURS AWARDED DATES TOTAL # OF CREDITS/HOURS: Name (print): License Number: 5

6 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: 6

7 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: 7

8 51357 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPISTS 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 1 Vermont License Number First Name - (Please print legibly using a dark blue or black pen and uppercase letters; fill in small check ovals entirely) Middle Name Last Name 1. Gender: Male Female 2. Are you Hispanic or Latino/a? Mexican or Mexican American Puerto Rican Cuban or Cuban American Other Hispanic, Latin, or Spanish Origin t hispanic Choose not to respond Birthdate (mm-dd-yyyy) Race? (check all that apply) American Indian or Alaska Native Asian or Asian American Black or African American Native Hawaiian or Pacific Islander White Other Choose not to respond 4. What is your highest OT-related degree? Associate Degree (AA, etc) Bachelor s Degree (BS, BA, etc) Master's Degree (MS, MA, etc) Specialist Degree / Certificate Doctorate (PhD, etc) Other (please specify) 5. In what year did you complete your highest related degree? 6. Enter the two-letter code for the state where you completed your highest related degree: (use CC for Canada, XX for other foreign countries) Name of other foreign country: 7. Are you certified by any certification board? yes, by the NBCOT yes, by the Society of hand therapists yes, by some other board no 8. Are you certified in a subspecialty by the American Occupational Therapy Association (AOTA)? yes, in neurology yes, in pediatrics yes, in gerontology Other (please specify) 9. In what year did you obtain your first OT license? Please continue on next page. Thank you

9 51357 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPISTS 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 2 Vermont License Number (Please re-enter your license number for scanning purposes) 10. Are you actively working in Vermont as an OT? 11. IF you are not actively working in Vermont as an OT, do you plan to start (or resume) work and/or clinical practice in Vermont within the next 12 months? 12. IF you are not actively work in Vermont as an OT, please describe your current employment status: (check all that apply) Actively working OUTSIDE Vermont in a position that requires your OT license Actively working in an OT position that does not require an OT license Actively working in a different field t currently working Retired * IF you are NOT actively working IN VERMONT as an OT, PLEASE STOP HERE AND RETURN SURVEY 13. Which of the following best describes your current employment arrangement at your primary Vermont practice location regarding direct client / patient care? Self employed Salaried employment Contract employment Hourly employment Temporary Employment Other 14. What are your employment plans for the next 12 months? Continue as you are Increase hours Decrease hours Stop working in VT as an Occupational Therapist Unsure Please continue on next page. Thank you

10 51357 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPISTS 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 3 Vermont License Number (Please re-enter your license number for scanning purposes) Please enter site information FOR EACH LOCATION where you provide direct patient care IN VERMONT. If you provide care at two locations in the same town, please enter a separate site for each. SITE ONE (principal site) - town for the Vermont location where you work, not a mailing address: Practice Name and Street address (not a mailing address): ZIP code: This site is a (please choose ONE): Hospital/Medical Center Acute care setting Private Practice Skilled Nursing Facility Health Clinic/Outpatient Facility Rehabilitation Unit Assisted Living Nursing Home School or College Mental Health Program Home Health Patients work site Business or industrial workplace Community / Social service agency Other: During how many weeks in a year do you work at this site as an OT: (48 weeks is considered "year round") - Weeks Per Year What is your primary specialty area of practice at this site? (select ONE) Hospital School systems Developmental disability Pediatrics Mental health Rehabilitation Alzheimer s and other forms of dementia Assisted living Aging in place Older driver safety and rehab Other geriatric Acute care Orthopedics Home Health Work and industry Other: Please indicate the average number of hours spent per working week at this site providing direct Client/Patient Care / Healthcare Services in the primary specialty mentioned above: Hours per week Please continue on next page. Thank you

11 51357 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPISTS 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 4 Vermont License Number (Please re-enter your license number for scanning purposes) What is your secondary specialty area of direct patient care at this site? (if any) Hospital School systems Developmental disability Pediatrics Mental health Rehabilitation Alzheimer s and other forms of dementia Assisted living Aging in place Older driver safety and rehab Other geriatric Acute care Orthopedics Home Health Work and industry Other: Please indicate the average number of hours spent per working week in the past year at this site on additional major activities: Administration / Management Teaching/Education/Research Other activities Please indicate the average number of hours spent per working week at this site providing direct Client/Patient Care / Healthcare Services in the secondary specialty mentioned above (if any): Hours per week * If you have a second practice site, continue on the next page. If you only have one practice site, stop here, but please return all 6 pages. Please return all sheets (6 pages) even if some are blank. Thank you

12 51357 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPISTS 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 5 Vermont License Number (Please re-enter your license number for scanning purposes) Please enter site information FOR EACH LOCATION where you provide direct patient care IN VERMONT. If you provide care at two locations in the same town, please enter a separate site for each. SITE TWO (if any) - town for the Vermont location where you work, not a mailing address: Practice Name and Street address (not a mailing address): ZIP code: This site is a (please choose ONE): Hospital/Medical Center Acute care setting Private Practice Skilled Nursing Facility Health Clinic/Outpatient Facility Rehabilitation Unit Assisted Living Nursing Home School or College Mental Health Program Home Health Patients work site Business or industrial workplace Community / Social service agency Other: During how many weeks in a year do you work at this site as an OT: (48 weeks is considered "year round") - Weeks Per Year What is your primary specialty area of direct patient care at this site? (select ONE) Hospital School systems Developmental disability Pediatrics Mental health Rehabilitation Alzheimer s and other forms of dementia Assisted living Aging in place Older driver safety and rehab Other geriatric Acute care Orthopedics Home Health Work and industry Other: Please indicate the average number of hours spent per working week at this site providing direct Client/Patient Care / Healthcare Services in the primary specialty mentioned above: Hours per week Please continue on next page. Thank you

13 51357 VERMONT DEPARTMENT OF HEALTH CENSUS OF OCCUPATIONAL THERAPISTS 2016 This census is designed to assess the distribution of occupational therapists throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 6 Vermont License Number (Please re-enter your license number for scanning purposes) What is your secondary specialty area of direct patient care at this site? (if any) Hospital School systems Developmental disability Pediatrics Mental health Rehabilitation Alzheimer s and other forms of dementia Assisted living Aging in place Older driver safety and rehab Other geriatric Acute care Orthopedics Home Health Work and industry Other: Please indicate the average number of hours spent per working week in the past year at this site on additional major activities: Administration / Management Teaching/Education/Research Other activities Please indicate the average number of hours spent per working week at this site providing direct Client/Patient Care / Healthcare Services in the secondary specialty mentioned above (if any): Hours per week If you work at more than two sites, please mark bubble, and describe the additional sites briefly, including location, setting, specialty, weeks and hours: more Please return all sheets (6 pages) even if some are blank. Thank you