Current through Register No. 40, October 3, 2024
(a) The renewal
application form shall:
(1) Be provided by the
board; and
(2) Contain 3 parts as
follows:
a. Part one, which shall be available
to the public, except for the information required by (c) and (d)
below;
b. Part 2, which shall be
held confidential by the board, except for the information required by (g)(5),
(g)(6), and (g)(7) below; and
c.
Part 3, which is available to the public.
(b) The renewal applicant shall:
(1) Complete the entire renewal application
form using a keyboard or by printing legibly in ink; and
(2) Complete all sections of the entire
renewal application form or designate them as not applicable.
(c) On part one of the renewal
application form the renewal applicant shall correct as necessary the home
mailing address.
(d) Also on part
one of the form the renewal applicant shall list the jurisdictions, other than
New Hampshire, where the applicant is currently licensed to practice.
(e) Also on part one of the form using the
"yes" and "no" columns provided, indicate whether:
a. During the past 27 months, or if not
previously reported, the applicant has been found guilty of, or entered a plea
of no contest to, any felony or misdemeanor;
b. During the past 27 months, or if not
previously reported, the applicant has been the subject of any disciplinary
action by any professional licensing authority;
c. During the past 27 months, or if not
previously reported, the applicant has been denied a license or other
authorization to practice in any state or jurisdiction; and
d. During the past 27 months, or if not
previously reported, the applicant has surrendered a license or other
authorization to practice issued by any state or jurisdiction in order to avoid
or settle disciplinary charges.
(f) Also on part one of the form the renewal
applicant shall place his or her signature and the date of signing below the
following preprinted statement:
"I acknowledge that knowingly making a false statement on
this application form is a misdemeanor under
RSA
641:2, I. I certify that the information I
have provided on all parts of the application form and in the documents that I
have personally submitted to support my application is complete and accurate to
the best of my knowledge and belief. I also certify that I have read the
statute and the rules of the Board and promise that, if I am licensed, I will
abide by them."
(g) On part
2 of the form a renewal applicant shall provide the applicant's:
(1) Full name;
(2) Home physical address;
(3) Home phone number or personal cell phone
number;
(4) Home mailing
address;
(5) Place of employment
name, if any;
(6) Place of
employment mailing address, if any;
(7) Place of employment phone number, if any;
and
(8) E-mail address at which the
applicant wishes to receive correspondence from the board.
(h) The renewal applicant shall use the boxes
provided to indicate which of the following addresses, if any, the board is
permitted to make available to the public:
(1) Home mailing address;
(3) Place of employment mailing address;
and
(4) None.
(i) The renewal applicant shall designate by
checking one of the appropriate boxes if the applicant wishes to receive
notification from the board by e-mail or regular mail.
(j) The renewal applicant shall verify his or
her social security number and make any necessary corrections to the preprinted
number by striking through the incorrect number and writing the corrected
number under the following preprinted statement:
"The Governing Board of your profession will deny licensure
if you refuse to submit your social security number (SSN). Your professional
license will not display your SSN. Your SSN will not be made available to the
public.
The Governing Board is required to obtain your social
security number for the purpose of child support enforcement and in compliance
with RSA
161-B:11. This collection of your social
security number is mandatory."
(k) Also on part 2 of the renewal application
form the renewal applicant shall indicate using the "yes" and "no" columns
provided, indicate whether:
(1) The applicant
has any reason to believe that the applicant will soon be the subject of a
disciplinary proceeding, settlement agreement or consent decree undertaken or
issued by a professional licensing board or any state or
jurisdiction;
(2) During the past
27 months, or if not previously reported, any malpractice claim has been made
against the applicant;
(3) During
the past 27 months, or if not previously reported, the applicant has for
disciplinary reasons been put on administrative leave, been fired for cause
other than staff reductions from a position at his or her place of employment,
or had any privileges limited, suspended or revoked in any:
a. Hospital;
b. Health care institution;
c. Home health care agency;
d. Educational institution; or
e. Other professional setting;
(4) During the past 27 months, or
if not previously reported, the applicant has been denied the privilege of
taking an examination required for any professional licensure; and
(5) During the past 27 months, or if not
previously reported, the applicant has any physical, mental or emotional
condition, or any alcohol or substance abuse problem, which could negatively
affect the applicant's ability to practice the profession for which licensure
is sought.
(l) On part 3
of the form the renewal applicant shall:
(1)
Place his or her full name and current New Hampshire license number;
and
(2) Indicate, by using the
check box provided, the allied health profession of licensure.
(m) Also on part three of the form
the renewal applicant shall use the designated columns to report the following
information about each continuing professional education course or professional
activity constituting maintenance of continuing competence completed since the
issuance of the initial license or the last licensure renewal:
(1) Its beginning and ending dates;
(2) Its title;
(3) The name of its sponsor or
provider;
(4) The clinical hours
attributable to it;
(5) The other
hours attributable to it; and
(6)
The total number of hours attributable to it.
(n) Also on part 3 of the form the renewal
applicant shall:
(1) Show in the space
provided the total hours of continuing professional education and professional
activity completed;
(2) Use the
designated columns to report the same information required by (h) above for
each course or professional activity he or she anticipates will be completed
between November 1 and December 31; and
(3) Show in the space provided the total
hours of continuing professional education and professional activity
anticipated to be completed between November 1 and December 31.
#9456, eff 4-17-09; ss by # 10061, eff 12-23-11; ss by
#10203, eff 19-19-12; ss by #10402, eff
8-23-13
The amended
version of this section by
New
Hampshire Register Volume 37, Number 06, eff.
1/20/2017 is not yet
available.
