Physical Therapist 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 Physical Therapist Assistant Renewal/Reinstatement Application Physical Therapy Renewal Clerk (802) 828-1505 www.vtprofessionals.org Current Expiration 09/30/2014 You Must Complete The Information Below: Renewal Period Covering 10/01/2014 through 09/30/2016 Renewal Application Fee $100.00 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.

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

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. Board of Physical Therapy Administrative Rule 4.1 Continuing Education Requirements (a) A physical therapist licensee must document completion of a total of 24 CCUs during the two-year licensing period preceding renewal. A physical therapist assistant licensee must document completion of 16 CCUs during the two-year licensing period preceding renewal. This provision shall apply to all renewal periods. (te: Since the new Rule became effective between renewal periods the Board will only require 23 hours of continuing competence for physical therapists and 8 hours of continuing competence for physical therapist assistants this renewal cycle. After September 30, 2014, the full 24 CCU s for physical therapists and 16 CCU s for physical therapist assistants will be required every two years.) Continuing Education Requirement (Check the box that applies to your license.) I have completed 16 hours of continuing education. 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

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

Section E: Expired License 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

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) 2014 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: 7

22309 VERMONT DEPARTMENT OF HEALTH CENSUS OF PHYSICAL THERAPIST ASSISTANTS 2014 This census is designed to assess the distribution of Physical Therapist 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. Thank you for your cooperation. 1 Vermont License Number 0 4 1 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 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 Prefer not to answer 4. What was your entry level physical therapist assistant degree or certificate? Certificate Associate Degree (AA, AS, etc) Bachelor s Degree (BA, BS, etc) Master's Degree (MA, MS, etc) Other 5. In what year did you complete your entry level physical therapist assistant education? 6. Enter the two-letter code for the state where you completed your entry level physical therapy education: (use CC for Canada, XX for other foreign countries) Name of other foreign country: 3. 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 Prefer not to answer 7. Please indicate the highest level of education (in any field) that you have completed as of today: Certificate Associate Degree (AA, AS, etc) Bachelor s Degree (BA, BS, etc) Master's Degree (MA, MS, etc) Doctorate (PhD, MD, DPT, etc) Other 8. Please indicate any Board Certifications for physical therapy you currently hold: Cardiovascular & Pulmonary Clinical Electrophysiology Geriatrics Neurology Orthopaedics Pediatrics Sports Women's Health Other (specify) Please continue on next page. Thank you. 22309

22309 VERMONT DEPARTMENT OF HEALTH CENSUS OF PHYSICAL THERAPIST ASSISTANTS 2014 This census is designed to assess the distribution of Physical Therapist 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. Thank you for your cooperation. 2 Vermont License Number - 0 4 1 (Please re-enter your license number for scanning purposes) 9. Do you hold current credentials (license, certification, educational degree) in any of the following fields, separate from your physical therapist assistant credentials: Art/Dance therapy Athletic training Chiropractic Massage therapy Naturopathic Medicine 10. In what year did you obtain your first PT assistant license? 13. Please describe your current employment status: (check all that apply) Working IN VERMONT in a position that requires a PT Assistant license Working outside Vermont in a position that requires a PT Assistant license Actively working in a PT-related position that does not require a PT Assistant license Actively working in a different field t currently working Retired Other - please specify 14. What are your plans for the next 12 months regarding direct client/patient care in Vermont? Nursing Occupational therapy Orthotics Prosthetics Other (specify) 11. In what year did you start practicing (anywhere) as a licensed physical therapist assistant? If never,leave blank. 12. In what year did you start practicing in Vermont as a licensed physical therapist assistant? If never,leave blank. Increase hours in patient care as a PTA in VT Decrease hours in patient care as a PTA in VT Seek work as a PTA in VT Seek work as a PTA outside VT Seek a non-clinical job Retire from work as a PTA Continue as you are Unknown * IF you are not providing direct patient care IN VERMONT as a Physical Therapist Assistant, PLEASE STOP HERE AND RETURN SURVEY Please return all sheets (6 pages) even if some are blank. Thank you. 22309

22309 VERMONT DEPARTMENT OF HEALTH CENSUS OF PHYSICAL THERAPIST ASSISTANTS 2014 This census is designed to assess the distribution of Physical Therapist 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. Thank you for your cooperation. 3 Vermont License Number 0 4 1 - (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: ZIP code for the Vermont location where you work, not a mailing address: Practice Name and Street Address: - This site is a (please choose ONE): Office-based Practice Hospital-based Outpatient Facility or Clinic Acute Care Hospital Inpatient Rehab Facility (IRF) Skilled Nursing Facility (SNF) / Long-term Care Health and Wellness Facility Industry US Military / Veterans Administration Patient's home / Home care School System (preschool/primary/secondary) Academic Institution (post-secondary) Research Center Other: During how many weeks did you work at this site as a Physical Therapy Assistant in the past year: (48 weeks is considered "year round") Weeks Per Year What is your primary specialty area of direct patient care at this site? (select ONE) General Physical Therapy Acute Care Cardiovascular & Pulmonary Clinical Electrophysiology Geriatrics Hand Rehabilitation Neurology Oncology Orthopedics Pediatrics Sports Women's Health Other: Please indicate the average number of hours of direct patient care (excluding emergency call) spent per working week in the past year at this site in your primary specialty area mentioned above: Hours per week Please continue on next page. Thank you. 22309

22309 VERMONT DEPARTMENT OF HEALTH CENSUS OF PHYSICAL THERAPIST ASSISTANTS 2014 This census is designed to assess the distribution of Physical Therapist 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. Thank you for your cooperation. 5 Vermont License Number 0 4 1- (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: ZIP code for the Vermont location where you work, not a mailing address: Practice Name and Street Address: - This site is a (please choose ONE): Office-based Practice Hospital-based Outpatient Facility or Clinic Acute Care Hospital Inpatient Rehab Facility (IRF) Skilled Nursing Facility (SNF) / Long-term Care Health and Wellness Facility Industry US Military / Veterans Administration Patient's home / Home care School System (preschool/primary/secondary) Academic Institution (post-secondary) Research Center Other: During how many weeks did you work at this site as a Physical Therapy Assistant in the past year: (48 weeks is considered "year round") Weeks Per Year What is your primary specialty area of direct patient care at this site? (select ONE) General Physical Therapy Acute Care Cardiovascular & Pulmonary Clinical Electrophysiology Geriatrics Hand Rehabilitation Neurology Oncology Orthopedics Pediatrics Sports Women's Health Other: Please indicate the average number of hours of direct patient care (excluding emergency call) spent per working week in the past year at this site in your primary specialty area mentioned above: Hours per week Please continue on next page. Thank you. 22309