Radiologic Technologist Renewal/Reinstatement Application

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1 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT Board of Radiologic Technology Renewal Clerk (802) Current Expiration 05/31/2015 Radiologic Technologist Renewal/Reinstatement Application You Must Complete The Information Below: Renewal Period Covering 06/01/2015 through 05/31/2017 License #: ---- License #: ---- Name: Address: City/State/ZIP: Renewal Application Fee $ [n Refundable Processing Fee] ($15.00 additional for each PRIMARY license, Radiography, Nuclear Medicine Technology or Radiation Therapy) Checks Payable to: Vermont Secretary of State For Office Use Only 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.

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. 26 V.S.A (a) Renewal and procedure for nonrenewal Licenses shall be renewed every two years without examination and on payment of the required fees. Each radiographer, nuclear medicine technologist, and radiation therapist licensed to practice by the board shall apply biennially for the renewal of a license. One month prior to the renewal date, the office of professional regulation shall send to each of those licensees a license renewal application form and a notice of the date on which the existing license will expire. The licensee shall file the application for license renewal and pay a renewal fee. In order to be eligible for renewal, an applicant shall document completion of no fewer than 24 hours of board-approved continuing education. Required accumulation of continuing education hours shall begin on the first day of the first full biennial licensing period following initial licensure. Continuing Education Requirement (Check the box that applies to your license.) I currently hold an ARRT Certification -OR- NMTCB Certification -OR- BOTH. My Radiologic Technologist license was first issued in Vermont on or after 06/01/2013; therefore I do not have to complete Continuing Education for this renewal cycle (0 hours). My Radiologic Technologist license was first issued in Vermont prior to 06/01/2013; and I have completed 24 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

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 D: Primary and Post Primary Certifications Primary Certification (check all that apply) (R) Radiography (T) Radiation Therapy (N) Nuclear Medicine Technology Post Primary Certification (check all that apply) (M) Mammography (VI) Vascular-Interventional Radiography (CT) Computer Tomography (CI) Cardiac-Interventional Radiography Section E: Expired Renewal If this is a late renewal, have you been practicing 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 **(REQUIRED)** 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) 2015 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 44547 VERMONT DEPARTMENT OF HEALTH Census of Radiologic Technologists 2015 This census is designed to assess the distribution of Radilogic Technologists 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 (example: ) First Name. Middle Name (Please print legibly using a dark blue or black pen and uppercase letters; fill in small check ovals entirely) 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 4. What is your highest earned degree or certificate related to this license? Associate Degree (AA, AS) Bachelor s Degree (BA, BS) Master's Degree (MA, MS. etc) Specialist Degree / Certificate Doctoral Degree (PhD, etc) Other Birthdate (mm-dd-yyyy) Race? (check all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Other Choose not to respond 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 currently enrolled in a Radiologic education program leading to a degree? t enrolled Associate Degree (AS, etc) Bachelor s Degree (BS, etc) Master's Degree (MS, etc) Doctorate (PhD, etc) Other - please specify: 8. What licenses do you maintain? Please select all that apply: 034 Ionizing Radiation Privileges (Physician) 049 Nuclear Medicine Technologist 050 Radiation Therapist 051 Radiologic Technologist (Radiography) 053 Radiologic Technologist Limited Chest 053 Rad. Tech. Limited Chest and Extremities 053 Rad. Tech. Limited Extremities 013 Dental Assistant with Radiology Priv. Other - please specify: Please continue on next page. Thank you

9 44547 VERMONT DEPARTMENT OF HEALTH Census of Radiologic Technologists 2015 This census is designed to assess the distribution of Radilogic Technologists 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. 9. In what state(s) do you hold an active license? State (postal) abbreviation(s): 10. What is your employment status? (check all that apply) (Please re-enter your license number for scanning purposes) Actively working in a position that requires a radiologic technologist license Working in a position that does not require a radiologic technologist license Actively working in a different field t currently working Retired Other - please specify: 11. In what areas do you hold credentials as a Radiologic Technologist? (check all that apply) General radiography Bone densitometry Cardiovascular-intervention Computed tomography Magnetic resonance imaging Mammography Nuclear Medicine Technology Nuclear Medicine Technology (NMTCB-CNMT) Nuclear Cardiology Technology (NMTCB-NCT) Positron Emission Technology (NMTCB-PET) Quality management Sonography Breast sonography Vascular sonography Cardiac-interventional Vascular interventional Registered radiologist assistant Diagnostic medical sonography (ARDMS-RDMS) Vascular technology (ARDMS-RVT) Diagnostic cardiac sonography (ARDMS-RDCS) Medical dosimetry (MDCB-CMD) Radiation therapy Other (specify) 12. Do you provide direct patient care in Vermont as a radiologic technologist? 13. If no, do you plan to start (or resume) direct patient care in Vermont as a radiologic technologist within the next 12 months? * IF you are NOT providing direct patient care IN VERMONT as a radiologic technologist, PLEASE STOP HERE AND RETURN SURVEY 14. How many years have you worked as a Radiologic Technologist in Vermont? 15. What are your employment plans for the next 12 months regarding direct patient care in Vermont? Increase hours in patient care Decrease hours in patient care Seek a non-clinical job Retire Continue as you are Unknown Please continue on next page. Thank you

10 44547 VERMONT DEPARTMENT OF HEALTH Census of Radiologic Technologists 2015 This census is designed to assess the distribution of Radilogic Technologists 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 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 - Which best describes the type of setting that most closely corresponds to this practice location (please choose ONE): Academic Institution Device manufacturer/distributor Diagnostic Imaging Center, Stationary Diagnostic Imaging Center, Mobile General hospital, inpatient department General hospital, outpatient department Outpatient/Community Clinic Physician Office Skilled Nursing Facility Other setting (please specify): In the past year, during how many weeks did you work at this site as a radiologic technologist: (48 weeks is considered "year round") Weeks Per Year What are your specialty area(s) of direct patient care at this site? (at most ONE per column) Primary Secondary (if any) General radiography Bone densitometry Cardiovascular-intervention Computed tomography Magnetic resonance imaging Mammography Nuclear Medicine Technology Nuclear Medicine Technology (NMTCB-CNMT) Nuclear Cardiology Technology (NMTCB-NCT) Positron Emission Technology (NMTCB-PET) Quality management Sonography Breast sonography Vascular sonography Cardiac-interventional Vascular interventional Registered radiologist assistant Diagnostic medical sonography (ARDMS-RDMS) Vascular technology (ARDMS-RVT) Diagnostic cardiac sonography (ARDMS-RDCS) Medical dosimetry (MDCB-CMD) Radiation therapy Other (specify) Average number of hours spent per working week at this site in the specialty(s) mentioned above: Primary Secondary Hours per week Please continue on next page. Thank you

11 44547 VERMONT DEPARTMENT OF HEALTH Census of Radiologic Technologists 2015 This census is designed to assess the distribution of Radilogic Technologists 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) If you provide care at two locations IN VERMONT, please describe the second one on this page. 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): Academic Institution Device manufacturer/distributor Diagnostic Imaging Center, Stationary Diagnostic Imaging Center, Mobile General hospital, inpatient department General hospital, outpatient department Outpatient/Community Clinic Physician Office Skilled Nursing Facility Other setting (please specify): In the past year, during how many weeks did you work at this site as a radiologic technologist: (48 weeks is considered "year round") Weeks Per Year What are your specialty area(s) of direct patient care at this site? (at most ONE per column) Primary Secondary (if any) General radiography Bone densitometry Cardiovascular-intervention Computed tomography Magnetic resonance imaging Mammography Nuclear Medicine Technology Nuclear Medicine Technology (NMTCB-CNMT) Nuclear Cardiology Technology (NMTCB-NCT) Positron Emission Technology (NMTCB-PET) Quality management Sonography Breast sonography Vascular sonography Cardiac-interventional Vascular interventional Registered radiologist assistant Diagnostic medical sonography (ARDMS-RDMS) Vascular technology (ARDMS-RVT) Diagnostic cardiac sonography (ARDMS-RDCS) Medical dosimetry (MDCB-CMD) Radiation therapy Other (specify) Average number of hours spent per working week at this site in the specialty(s) mentioned above: Primary Secondary Hours per week If you work at more than two sites please check bubble and describe briefly in margin. Thank you

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