Licensed Nursing Assistant Renewal/Reinstatement Application

Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Licensed Nursing Assistant Renewal/Reinstatement Application Board of Nursing Renewal Clerk (802) 828-1505 www.vtprofessionals.org Current Expiration 11/30/2016 You Must Complete The Information Below: Renewal Period Covering 12/01/2016 through 11/30/2018 Renewal Application Fee $45.00 n Refundable Processing Fee Checks Payable to: Vermont Secretary of State 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: ( ) - E-Mail Address: Date of Birth (MM/DD/YYYY) Gender: (Circle One) / / Male Female

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) 241-2319. 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) 828-2515 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

Section C: Vermont Mandatory Credential and Fitness Questions Circle or for each of these questions. If the answer is, follow the instructions provided. Since your license was last renewed (or since it was issued if within the last two years): Have you committed acts of abuse, neglect, or misappropriation of patient property? If, provide a detailed written explanation and attach all related documents. 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 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. Are you currently participating in a supervised program or professional assistance program which monitors you in order to assure that you are not engaging in the use of alcohol or controlled substances? If, please provide the contract/stipulation under which you are practicing. Name (print): License Number: 3

Section D: Program & Practice Requirements Board of Nursing Administrative Rule 3.5(a) Renewal; Active Practice Requirement (a) To renew a nursing assistant license the nursing assistant shall document a minimum of 50 days (400 hours) in the last two years of paid compensation as a licensed nursing assistant. (1) Eight hours are equivalent to one day of nursing assistant practice. (2) Only time acquired while the LNA license is active will be accepted toward the active practice requirement. (b) Applicants may be required to provide a job description or other evidence that they have been engaged in active LNA practice. Documentation submitted under this subsection must be certified as true by employers or other appropriate persons. (c) A licensee who does not meet the active practice requirement shall repeat the nursing assistant education program and competency examination. Program and Practice Experience Requirement (Check the box that applies to your license.) I have completed a Nursing Assistant program within the last two (2) years [12/01/2014 11/30/2016]; therefore I do not have to meet the practice requirement. I have practiced as a Nursing Assistant under the supervision of a licensed Nurse (RN or LPN) for paid compensation for 50 days (400 hours) within the last two (2) years [12/01/2014 11/30/2016]. I have NOT met the program or practice experience requirement (A licensee who does not meet the active practice requirement shall repeat the nursing assistant education program and competency examination.) Section E: Audit Information The Office of Professional Regulation reserves the right to verify information submitted by licensees for renewal through a random employment audit. You must retain all names and complete dates of employment for the two years prior to this renewal application. If you are selected for an audit you will need to submit verification of employment from your employer(s) on the employer s letterhead. The letter must include the date range of your employment (mm/dd/yyyy mm/dd/yyyy) and the total number of hours worked within the past 2 years, and the name and title of your nursing supervisor. Name (print): License Number: 4

Section F: Late Renewals If you are renewing more than 30 days past your expiration date, you must submit: A completed renewal application Verification of employment from your employer(s) on the employer s letterhead. The letter must include the date range of your employment (mm/dd/yyyy mm/dd/yyyy) and the total number of hours worked within the past 2 years. It must also indicate the supervisor s title and license type. 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 G: 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: 5

Office of Professional Regulation Vermont Secretary of State Attn: Renewal Clerk 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Phone: (802) 828-1505 Fax: (802) 828-2465 www.vtprofessionals.org Vermont Office of Professional Regulation Survey (optional) 2016 Renewal License #: Name: ---- 1. 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: 6

19556 VERMONT DEPARTMENT OF HEALTH CENSUS OF LICENSED NURSE ASSISTANTS 2016 This census is designed to assess the distribution of Licensed Nurse Assistants throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) 863-7300 or 1-800-869-2871. If you prefer, do it online instead: http://survey.healthvermont.gov/s3/lna16 1 Vermont License Number 0 7 5 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 Birthdate (mm-dd-yyyy) - - 1. Gender: Male Female Other 2. Are you Hispanic or Latino/a? (check all that apply) Mexican or Mexican American Puerto Rican Cuban or Cuban American Other Hispanic, Latin, or Spanish Origin t hispanic Prefer not to answer 3. Race? (check all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Other Prefer not to answer 4. What is your highest earned degree? Less than High School High School or GED Technical School Some College but no degree Associate Degree (AA, AS, etc) Bachelor s Degree (BA, BS, etc) Other 5. In what year did you complete your highest earned degree? 6. Enter the two-letter code for the state where you completed your highest degree: (use CC for Canada, XX for other foreign countries) Name of other foreign country: 7. Did you participate in an LNA training program IN VERMONT, within the last 5 years, in addition to the education mentioned above? If yes, how long did you have to wait to get into the training program? months 8. Are you currently enrolled in a nursing education program leading to a degree/certificate: t Enrolled LPN Program Associate Degree Program Bachelor s Degree Program Other 9. For how many years have you been working as an LNA (in any state)? Please continue on next page. Thank you. 19556

19556 VERMONT DEPARTMENT OF HEALTH CENSUS OF LICENSED NURSE ASSISTANTS 2016 This census is designed to assess the distribution of Licensed Nurse Assistants throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) 863-7300 or 1-800-869-2871. If you prefer, do it online instead: http://survey.healthvermont.gov/s3/lna16 2 Vermont License Number - 0 7 5 (Please re-enter your license number for scanning purposes) 10. In what state(s) (other than Vermont) do you hold an active LNA license? - state (postal) abbreviation(s) 11. What is your employment status? (check all that apply) Working IN VERMONT in a position that requires an LNA license Working outside Vermont in a position that requires an LNA license Actively working in a different field t currently working Retired 12. If not currently working as an LNA, please indicate the reasons: (check all that apply) 13. If not working in Vermont as an LNA, do you plan to start (or resume) working in Vermont as an LNA within the next 12 months? * Taking care of home and family Unable to perform the duties Inadequate salary and/or benefits Attending school Unable to find an LNA position Other IF you are NOT working IN VERMONT as an LNA, PLEASE STOP HERE AND RETURN SURVEY 14. For how many years have you worked in Vermont as an LNA? 15. If now working as an LNA only part-time, please indicate the reasons: (check all that apply) Personal choice Attending school Unable to find a full-time LNA position Other 16. Please answer regarding your knowledge of English and other languages: English is my second language, my first language is: English is my native language, but I also speak these languages: I only speak English 17. Have you participated in the OASIS program (regarding psychotic drug usage in nursing homes)? Please return all sheets (4 pages) even if some are blank. Thank you. 19556

19556 VERMONT DEPARTMENT OF HEALTH CENSUS OF LICENSED NURSE ASSISTANTS 2016 This census is designed to assess the distribution of Licensed Nurse Assistants throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) 863-7300 or 1-800-869-2871. If you prefer, do it online instead: http://survey.healthvermont.gov/s3/lna16 3 Vermont License Number 0 7 5 - (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 each as a separate site. SITE ONE (principal site) - TOWN for the Vermont location where you work, not a mailing address: Practice Name: Street Address: ZIP code for the Vermont location where you work, not a mailing address: - Which best describes the type of setting that most closely corresponds to this practice location: (please choose ONE): Assisted living facility Community Health Center Home health agency Hospital, ambulatory care Hospital, inpatient care Mental health center Nursing home Physician practice Private home/residence Residential care School Other (specify): * If During how many weeks in a year do you work at this site as an LNA? (48 weeks is considered "year round") Weeks Per Year What is the average number of hours you spend per working week at this site providing direct client/patient care: Hours per week you have a second practice site, continue on the next page. If you only have one practice site, stop here, but please return all 4 pages. Please continue on next page. Thank you. 19556

19556 VERMONT DEPARTMENT OF HEALTH CENSUS OF LICENSED NURSE ASSISTANTS 2016 This census is designed to assess the distribution of Licensed Nurse Assistants throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) 863-7300 or 1-800-869-2871. If you prefer, do it online instead: http://survey.healthvermont.gov/s3/lna16 4 Vermont License Number 0 7 5- (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 each as a separate site. SITE TWO (if any) - TOWN for the Vermont location where you work, not a mailing address: Practice Name: Street Address: ZIP code for the Vermont location where you work, not a mailing address: - Which best describes the type of setting that most closely corresponds to this practice location: (please choose ONE): Assisted living facility Community Health Center Home health agency Hospital, ambulatory care Hospital, inpatient care Mental health center Nursing home Physician practice Private home/residence Residential care School Other (specify): During how many weeks in a year do you work at this site as an LNA? (48 weeks is considered "year round") Weeks Per Year What is the average number of hours you spend per working week at this site providing direct client/patient care: Hours per week If you work at more than two sites, please mark bubble, and describe the additional sites briefly, including location, setting, weeks and hours: more Please return all sheets (4 pages) even if some are blank. Thank you. 19556