New Hampshire Code of Administrative Rules
Phy - Governing Board of Physical Therapists
Chapter Phy 400 - CONTINUED STATUS
Part Phy 404 - CONDITIONALLY REINSTATED LICENSES
Section Phy 404.05 - Supervision Form
Universal Citation: NH Admin Rules Phy 404.05
Current through Register No. 40, October 3, 2024
(a) The supervision form shall:
(1) Be the "Supervision Form"
dated March 25, 2015;
(2) Be
provided by the board and available on the boards web site,
www.nh.gov/alliedhealth ;
(3) Be completed legibly in ink or using a
keyboard; and
(4) Be signed and
dated below the following preprinted statement which asserts:
"By signing this form I state that I have read and understood the applicable rules of supervision or order of the Board for supervision, agree to undertake the duties of supervision set forth in the rules or order of the Board, agree to be responsible for the acts and omissions of any person to whom I delegate the duties of supervision, and acknowledge that my own or my delegate's failure to comply with the rules or order of the Board might result in disciplinary sanctions."
(b) The signature required by (a)(4) above shall constitute the signer's:
(1) Assertion
that the signer has read and understood the rules or order of the board
governing the supervision;
(2)
Agreement to undertake the duties of supervision;
(3) Agreement to take responsibility for the
acts and omissions of any individual to whom the signer delegates the duties of
supervision; and
(4) Statement of
understanding that the failure of the signer or the signer's delegate to follow
the rules or order of the Board governing the supervision has the potential to
subject the signer to disciplinary sanctions.
#9431, eff 3-19-09
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