Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Clinical Social Workers 802-828-1505 renewalclerk@sec.state.vt.us www.vtprofessionals.org Licensed Independent Clinical Social Workers Renewal/Reinstatement Application Current Expiration 01/31/2016 You Must Complete The Information Below: Renewal Period Covering 02/01/2016 through 01/31/2018 Renewal Application Fee $150.00 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 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. Clinical Social Worker Advisor Administrative Rule 3.2 Continuing Education Requirements All licensees shall attest to the completion of 20 contact hours of eligible education taken within the previous twoyear license period. At least 15 contact hours shall consist of formal education experiences. At least one and one half hours of the total 20 hours shall be in ethics of social work practice, including such issues as boundaries, confidentiality, and dual relationships. more than five hours may be in informal or self-directed educational activities. Continuing Education Requirement (Check the box that applies to your license.) My Social Worker license was first issued in Vermont on or after 02/01/2014; therefore I do not have to complete Continuing Education for this renewal cycle (0 hours). My Social Worker license was first issued in Vermont prior to 02/01/2014; and I have completed 20 hours of continuing education (1.5 hours in Ethics). 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 Renewal 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 **(REQUIRED)** Signature Date (MM/DD/YYYY)**(REQUIRED)** 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) 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: 7
23286 VERMONT DEPARTMENT OF HEALTH CENSUS OF SOCIAL WORKERS 2016 This census is designed to assess the distribution of clinical social workers 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. The census may be completed at: http://survey.healthvermont.gov/s3/csw16 1 Vermont License Number 0 8 9 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 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 social work degree? Bachelor s Degree (BSW, BA) Master's Degree (MSW, MA) Doctoral Degree (DSW, PhD) Social Work Degree Other 5. Do you have two years of supervised clinical experience? Don't know Birthdate (mm-dd-yyyy) - - 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 Choose not to respond 6. In what year did you complete your highest SW degree? 7. Enter the two-letter code for the state where you completed your highest SW degree: (use CC for Canada, XX for other foreign countries) Name of other foreign country: 8. In what year did you obtain your first clinical social worker license? 9. Are you certified as a clinical social worker by the American Board of Examiners in Clinical Social Work? Don't know 10. Are you listed on the National Association of Social Workers Clinical Register? Don't know Please continue on next page. Thank you. 23286
23286 VERMONT DEPARTMENT OF HEALTH CENSUS OF SOCIAL WORKERS 2016 This census is designed to assess the distribution of clinical social workers 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. The census may be completed at: http://survey.healthvermont.gov/s3/csw16 2 Vermont License Number - 0 8 9 (Please re-enter your license number for scanning purposes) 11. Are you actively working in Vermont as a clinical social worker? 12. If you are NOT actively working in Vermont as a social worker, do you plan to start (or resume) work in Vermont within the next 12 months? 13. If you are NOT actively working in Vermont as a social worker, please describe your current employment status: (check all that apply) Actively working OUTSIDE Vermont in a position that requires a clinical social worker license Actively working in a position that does not require a clinical social worker license Actively working in a field other than clinical social work t currently working Retired Other (please specify) * IF you are NOT actively working IN VERMONT as a social worker, PLEASE STOP HERE AND RETURN SURVEY 14. What are your employment plans regarding working in Vermont as a social worker for the next 12 months? 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. 23286
23286 VERMONT DEPARTMENT OF HEALTH CENSUS OF SOCIAL WORKERS 2016 This census is designed to assess the distribution of clinical social workers 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. The census may be completed at: http://survey.healthvermont.gov/s3/csw16 3 Vermont License Number 0 8 9 - (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 on a separate page. SITE ONE (principal site) - town for the Vermont location where you work, not a mailing address: Practice Name and Street address (not a mailing address): ZIP code: This site is a (please choose ONE): Private Solo Practice Private Group Practice Mental Health Clinic / Agency Substance Abuse Treatment Facility Health Clinic/Outpatient Facility Social Service Agency Public Health Agency Home Health Agency Criminal Justice Agency Other Government Agency Psychiatric Hospital Hospital/Medical Center School or College Nursing Home Hospice Other: - Please enter the number of weeks in a year during which you work at this site as a clinical social worker (48 weeks is considered "year round") Weeks Per Year What is your primary specialty area of direct patient care at this site? (select ONE) Children and Families Adolescents (13-18 years old) Adults (18-65 years old) Older Adults (65+ years old) Veterans Interpersonal Violence Health Mental Health Addiction 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. 23286
23286 VERMONT DEPARTMENT OF HEALTH CENSUS OF SOCIAL WORKERS 2016 This census is designed to assess the distribution of clinical social workers 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. The census may be completed at: http://survey.healthvermont.gov/s3/csw16 4 Vermont License Number 0 8 9- (Please re-enter your license number for scanning purposes) What is your secondary specialty area of direct patient care at this site? (if any) Children and Families Adolescents (13-18 years old) Adults (18-65 years old) Older Adults (65+ years old) Veterans Interpersonal Violence Health Mental Health Addiction 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 secondary specialty area mentioned above: Please answer the following questions for your work at this site: I will accept new patients here: I participate in Medicaid here: I accept new Medicaid patients here: I participate in Medicare here: I accept new Medicare patients here: Hours per week Please indicate the average number of hours spent per working week in the past year at this site on additional major activities: Clinical Supervision Community & Prevention Number of clinical social workers at this practice location: Is supervision available at this site? Don't know Forensics, consulting, etc n clinical consultation Administration / Management Teaching/Education/Research * If you have a second practice site, continue on the next page. If you only have one practice site, stop here, but please return all 6 pages. Other activities Please return all sheets (6 pages) even if some are blank. Thank you. 23286
23286 VERMONT DEPARTMENT OF HEALTH CENSUS OF SOCIAL WORKERS 2016 This census is designed to assess the distribution of clinical social workers 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. The census may be completed at: http://survey.healthvermont.gov/s3/csw16 5 Vermont License Number 0 8 9- (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 on a separate page. SITE TWO (if any) - town for the Vermont location where you work, not a mailing address: Street address (not a mailing address): ZIP code: This site is a (please choose ONE): Private Solo Practice Private Group Practice Mental Health Clinic / Agency Substance Abuse Treatment Facility Health Clinic/Outpatient Facility Social Service Agency Public Health Agency Home Health Agency Criminal Justice Agency Other Government Agency Psychiatric Hospital Hospital/Medical Center School or College Nursing Home Hospice Other: - Please enter the number of weeks in a year during which you work at this site as a clinical social worker (48 weeks is considered "year round") Weeks Per Year What is your primary specialty area of direct patient care at this site? (select ONE) Children and Families Adolescents (13-18 years old) Adults (18-65 years old) Older Adults (65+ years old) Veterans Interpersonal Violence Health Mental Health Addiction 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. 23286
23286 VERMONT DEPARTMENT OF HEALTH CENSUS OF SOCIAL WORKERS 2016 This census is designed to assess the distribution of clinical social workers 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. The census may be completed at: http://survey.healthvermont.gov/s3/csw16 6 Vermont License Number 0 8 9- (Please re-enter your license number for scanning purposes) What is your secondary specialty area of direct patient care at this site? (if any) Children and Families Adolescents (13-18 years old) Adults (18-65 years old) Older Adults (65+ years old) Veterans Interpersonal Violence Health Mental Health Addiction 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 secondary specialty area mentioned above: Hours per week Please indicate the average number of hours spent per working week in the past year at this site on additional major activities: Clinical Supervision Community & Prevention Forensics, consulting, etc n clinical consultation Administration / Management Teaching/Education/Research Other activities Please answer the following questions for your work at this site: I will accept new patients here: I participate in Medicaid here: I accept new Medicaid patients here: I participate in Medicare here: I accept new Medicare patients here: Number of clinical social workers at this practice location: Is supervision available at this site? Don't know If you work at more than two sites, please mark bubble, and describe the additional sites briefly, including location, setting, specialty, weeks and hours: more Please return all sheets (6 pages) even if some are blank. Thank you. 23286