Polysomnography Technologist-Holder of a ......Verification of RPSGT Credentials 2. Please arrange...

New Jersey Office of the Attorney GeneralDivision of Consumer Affairs

State Board of Polysomnography124 Halsey Street, 6th Floor, P.O. Box 45051

Newark, New Jersey 07101(973) 273-8093

Polysomnography Technologist - Holder of a Polysomnographic Technician’s License

Date:________________________________

Anonrefundableapplicationfilingfeeof$100.00andalicensefeeof$500.00(foratotalof$600.00)intheformofacheckormoneyordermadeouttotheStateofNewJersey,mustbesubmittedwiththisapplication.(Applicantsshouldunderstandthatifthefeesarepaidwithapersonalcheck,andthecheckisreturnedbythebankduetoinsufficientfunds,thenextstepinthelicensureorcertificationprocesswillbedelayeduntilthefeesarepaid.)

TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants,without theirconsent.However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponsetootherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddressofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureofyourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleasedtothepublic.Oneofyouraddressesmustincludeastreet,city,stateandZIPcode.

InformationthatyouprovideonthisapplicationmaybesubjecttopublicdisclosureasrequiredbytheOpenPublicRecordsAct(OPRA).

Please print clearly. You must answer all of the questions on this application.

Personal Information Dateofbirth:_______________________ MonthDayYear

Placeofbirth: ______________________ CityState

Mr.1. Name Mrs. ____________________________________________________________ (______________________) Ms. Lastname Firstname Middleinitial Maidenname

2. Address

Home:_________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode County

____________________________________ _________________________________ Telephonenumber(includeareacode) E-mailaddress

Business:_______________________________________________________________________________________ Nameofcompany Telephonenumber(includeareacode)

________________________________________________________________________________________ Street City State ZIPcode County

Mailing:________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode County

Datereceived:_________________________Dateofexamination:_________________________

Attachaclear,full-facepassport-stylephotograph(2˝x2˝)ofyourheadandshoulders,takenwithinthepastsixmonths.A photo is requiredwith eachapplication.

Donotuse staples toattach thephoto.

Page1of14Revised:8/7/18

3. SocialSecurityNumber YoumustprovideyourSocialSecuritynumbertotheBoardorCommittee.Failuretodosowillresultindenial/nonrenewalof licensureorcertification.

*SocialSecurityNumber: __________ -____________ -___________

*PursuanttoN.J.S.A.54:50-24etseq.oftheNewJerseytaxationlaw,N.J.S.A.2A:17-56.44eoftheNewJerseyChildSupportEnforcementLaw,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theBoardorCommitteeisrequiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovideyourSocialSecuritynumberto:

a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeofreviewing compliancewithStatetaxlawandupdatingandcorrectingtaxrecords;

b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest;and

c. theNational PractitionerDataBank and theH.I.P.DataBank,when reporting adverse actions relating to health care professionals.

4. Citizenship/ImmigrationStatus

FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcertificatestoU.S.citizensorqualifiedaliens. Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofficeofU.S. CitizenshipandImmigrationServices(USCIS).

U.S.citizen AlienlawfullyadmittedforpermanentresidenceinU.S. Otherimmigrationstatus

Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe USCISat:1-800-375-5283.

5. ChildSupport(You must answer a, b, c and d.)

Pleasecertify,underpenaltyofperjury,thefollowing:

a. Doyoucurrentlyhaveachild-supportobligation? Yes No

(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No

(2)If“Yes,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No

b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No

c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No

d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No

InaccordancewithN.J.S.A.2A:17-56.44d,ananswerof“Yes”toanyofthequestionsa(1)throughdwillresult inadenialoflicensureorcertification.Furthermore,anyfalsecertificationoftheabovemaysubjectyoutoapenalty,including,butnotlimitedto,immediaterevocationorsuspensionoflicensureorcertification.

___________________________________ ___________________________________ ________________________ Applicant’sname(pleaseprint) Applicant’ssignature Date

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6. IllegalUseofControlledDangerousSubstances

Thequestionbelowpertainstotheillegaluseofcontrolleddangeroussubstances.Pleasereadthedefinitionscarefully.Yourresponseswillbetreatedconfidentiallyandretainedseparately.Pleasebeawarethatyouhavetherighttoelectnottoanswerthisquestionifyouhavereasonablecausetobelievethatansweringmayexposeyoutothepossibilityofcriminalprosecution.Inthatevent,youmayasserttheFifthAmendmentprivilegeagainstself-incrimination.AnyclaimofFifthAmendmentprivilegemustbemadeingoodfaith.IfyouchoosetoasserttheFifthAmendment,youmustdosoinwriting.Youmustfullyrespondtoallotherquestionsontheapplication.YourapplicationforlicensureorcertificationwillbeprocessedifyouclaimtheFifthAmendmentprivilegeagainstself-incrimination.Youshouldbeaware,however,thatyoumaylaterbedirectedbytheAttorneyGeneraltoansweraquestionthatyouhaverefusedtoansweronthebasisontheFifthAmendment,providedthattheAttorneyGeneralfirstgrantsyouimmunityaffordedbystatutorylaw,(N.J.S.A.45:1-20).

“Currently”doesnotmeanonthedayof,orevenintheweeksormonthsprecedingthecompletionofthisapplication.Rather,itmeansrecentlyenoughsothattheuseofdrugsmayhaveanongoingimpactonone’sfunctioningasalicensee,orwithintheprevious365days,whicheverislonger.

“Illegal use of controlled dangerous substance”meanstheuseofacontrolleddangeroussubstanceobtainedillegally(e.g.heroinorcocaine)aswellastheuseofcontrolleddangeroussubstanceswhicharenotobtainedpursuanttoavalidprescriptionornottakeninaccordancewiththedirectionsofalicensedhealthcarepractitioner.

a. Areyoucurrentlyengagedintheillegaluseofcontrolleddangeroussubstances?(Asstatedabove,“currently”isdefinedas “recentlyenough…[to]haveanongoingimpact…”or“withintheprevious365days,”whicheverislonger.)

Yes No

Ifyouanswered“Yes,”areyoucurrentlyparticipatinginasupervisedrehabilitationprogramorprofessionalassistanceprogram thatmonitorsyouinordertoassurethatyouarenotengagingintheillegaluseofcontrolleddangeroussubstances?

Yes No

_____________________________________________________ ___________________________________ Applicant’ssignature Date

7. Have you ever changed your name? Yes NoIf “Yes,” please submit with this application a copy of the marriage certificate, divorce decree or court order.

8. Do you currently hold, or have you ever held, a professional license or certificate of any kind in New Jersey, any other state, the District of Columbia or in any other jurisdiction Yes No

If “Yes,” for each license or certificate held, provide the date(s) held and the number(s). If the license or certificate was issued under a different name, please provide that name. ____________________________________________________________________

First name Last name Middle initial

_____________________ _______________________ ____________________________ ____________________ Number State or jurisdiction that issued the license or certificate Type of license or certificate Date issued/expired





9. Have you ever been disciplined or denied a professional license or certificate of any kind in New Jersey, any other state, the Districtof Columbia or in any other jurisdiction? Yes No

10. Have you ever had a professional license or certificate of any type suspended, revoked or surrendered in New Jersey, any other state,the District of Columbia or in any other jurisdiction? Yes No

11. Has any action (including the assessment of fines or other penalties) ever been taken against your professional practiceby any agency or certification board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?

Yes No

12. Have you ever been named as a defendant in any litigation related to the practice of polysomnography or other professional practicein New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

13. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention (P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle

violations such as driving while impaired or intoxicated must be.) Yes No

14. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,

non vult, nolo contendere, no contest, or a finding of guilt by a judge or jury. Yes No

If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete

explanation. (Attach additional sheets of paper to this application.)

15. Are you aware of any investigation pending against a professional license or certificate issued to you by a professional board in New

Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No

16. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any otherjurisdiction? Yes No

17. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional grouprelated to the practice of polysomnography or other professional practice in New Jersey, any other state, the District of Columbia or

in any other jurisdiction? Yes No

If the answer to any of the above questions, numbers 9 through 17, is “Yes,” provide a complete explanation of the circumstancesleading to the action, and any supporting documentation, on separate sheets of paper.

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Technologist Education - Holder of a Technician’s License

1. Listthesourcesfromwhichyoucompletedten(10)continuingeducationcreditsoverthepastyear.Inaddition,youmustalsoprovideacopyoftheCertificateofCompletionforeverycourseyouhavetaken.

Course/MethodofObtainingContinuingEducationCredits NumberofCredits

_____________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _______________________

_____________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _______________________

Verification of RPSGT Credentials

2. PleasearrangefortheBoardofRegisteredPolysomnographicTechnologiststosubmitevidencethatyouhavesuccessfullycompletedthecertificationexaminationdirectlytotheStateBoardofPolysomnography,P.O.Box45051,Newark,NJ07101.

By E-mail (preferred)

In order to expedite processing of your application - you can have theBRPT e-mail the StateBoard of Polysomnography verificationofyourRPSGTcredential.Pleasee-mailtheBPRTatinfo@brpt.org.

PleasebesuretotypeRPSGT verificationintheSubjectlineofyoure-mail.

IncludethefollowinginformationintheBodyofyoure-mail:

Your Full Name

Your RPGST Credential Number

I am requesting that the BRPT please forward verification of my RPSGT credential to the State Board of Polysomnography at [email protected]

By U.S. Mail

Youcanwrite toBRPTandhaveyourofficialBoardofRegisteredPolysomnographicTechnologistsverification sentdirectly totheBoardofficeat:StateBoardofPolysomnography,P.O.Box45051,Newark,NewJersey07101.

Basic Life Support

Youmustprovideproofthatyouholdacurrent(notexpired)certificationinBasicLifeSupportfortheHealthProviderfromthe AmericanHeartAssociation(AHA)orCardioPulmonaryResuscitation/AutomatedExternalDefibrillator(CPR/AED)fortheProfessional Rescuer from theAmericanRedCross, or another entity determinedby theDepartment ofHealth to complywithAHACPR guidelines.

Pleaseprovideacopy(frontandback)ofyourcertification.

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AffidAvit

This affidavit is to be executed by the applicant before a notary public:

Stateof:__________________________________________________

Countyof:________________________________________________

I, ________________________________________________ , inmaking this application to theStateBoard ofPolysomnography,for licensure or certification under the provisions ofTitle 45 of theGeneral Statutes ofNew Jersey and theRules of the StateBoard of Polysomnography, swear (or affirm) that I am the applicant and that all information provided in connectionwiththisapplicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefulldisclosuresmaybedeemedsufficienttodenylicensureorcertificationortowithholdrenewaloforsuspendorrevokealicenseorcertificateissuedbytheBoard.

Ifurtherswear(oraffirm)thatIhavereadN.J.S.A.45:14G-1etseq.,togetherwiththeRulesandRegulationsoftheStateBoardofPolysomnography,N.J.A.C.13:44L-1.1through6.1,andfullyunderstandthatinreceivinglicensureorcertificationfromtheBoard,Ibindmyselftobegovernedbythem.

Furthermore, I voluntarily consent to a thorough investigation ofmy present and past employment and other activities forthepurposeofverifyingmyqualificationsforlicensureorcertification.Ifurtherauthorizeallinstitutions,employers,agenciesandallgovernmentalagenciesandinstrumentalities(local,state,federalorforeign)toreleaseanyinformation,filesorrecordsrequestedbytheBoard.

__________________________________________________ Signatureofapplicant

Swornandsubscribedtobeforemethis__________________

dayof ____________________________ ,______________ MonthYear

__________________________________________________ NameofNotaryPublic(pleaseprint)

__________________________________________________ SignatureofNotaryPublic

Affix Seal Here

} ss.

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New Jersey Office of the Attorney General

Division of Consumer AffairsState Board of Polysomnography

P.O. Box 45051Newark, New Jersey 07101

(973) 273-8093

CertifiCAtion And AuthorizAtion form for A CriminAl history BACkground CheCk

Directions:Answerallofthequestionsonthisform.

1. Name _________________________________________________________ ( ________________________) LastFirstMiddle MaidenName

2. Address___________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode

3. Dateofbirth____/____/____ Sex: Male FemaleMonthDayYear

4. SocialSecuritynumber_________/_____ / ________

5. HaveyoucompletedthefingerprintingprocessforanyBoard or Committee of the New Jersey Division of Consumer AffairssinceNovember2003? Yes No

If“No,”youwillreceiveaseparatemailingfromtheBoardorCommitteeregardingthecriminalhistoryrecordbackgroundcheckprocess.Nopaymentisnecessaryasofnow.

If“Yes,”pleaseprovidethefollowinginformationandfollowtheinstructionsoutlinedbelow:

_______________________________________________ _______________________________________________ BoardorcommitteerequiringthefingerprintingMonthandyearyouwerefingerprinted

If youwere fingerprinted afterNovember 2003 as part of the criminal history background process for licensure orcertificationbyanyotherBoard or Committee of the New Jersey Division of Consumer Affairs (abackgroundcheckconductedfortheDepartmentofEducation,anotherstateagencyoranotherstatedoesnotapply)youwillnotberequiredtobefingerprintedasecondtime.However,theDivisionmustperformacriminalhistorybackgroundcheckeachtimeyouap-plyforlicensureorcertification.The fee for this service is 18.75.PaymentshouldbemadeintheformofacheckormoneyorderpayabletotheStateofNewJerseyandshouldaccompanyyourapplicationpacket.

6. Haveyoueverbeenarrestedand/orconvictedofacrimeoroffense?(Minortrafficoffensessuchasaparkingorspeedingviolationsneednotbelisted.) Yes No

Every such conviction on record must be disclosed. Atruecopyofeverypolicereport,judgmentofconviction,sentencing orderandterminationofprobationorder,ifapplicable,must besubmittedwiththisform.Anydocuments(includingemployer orsupervisorlettersofreference,ifapplicable)whichpresentclearandconvincingevidenceofrehabilitationmust besubmitted withthisform.Failure to follow these instructions may result in the denial of an initial application. Note: Copiesofjudgments,sentencingandterminationofprobationordersmaybeobtainedfromtheclerkofthecounty wherethoseorders,disposingoftheconviction,wereissuedandfiled. Your continuing responsibility to disclose convictions of crimes or offenses:Youmust notifytheBoardorCommittee withinfive(5)businessdaysifyouareconvictedofanycrimesoroffensesafterthisformhasbeencompleted.

Mr. Mrs. Ms.

BoardorCommittee________________________

Official Use Only

Resubmit________________________

Official Use OnlyDualLicense

LicenseType1________________________

Applicant’sNumber________________________

LicenseType2________________________

Applicant’sNumber________________________

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CertifiCAtion

I, ______________________________________________, in making this application to the Board or Committee forcertification or licensure, certify that I am the applicant and that all of the information provided in connectionwith thisapplicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefulldisclosuresmaybedeemedsufficienttodenycertificationorlicensureortowithholdrenewaloforsuspendorrevokeacertificateorlicenseissuedbytheBoardorCommittee.

I voluntarily consent to a thorough investigation ofmy present and past employment and other activities for the purposeof verifyingmyqualifications for certification or licensure. I further authorize all institutions, employers, agencies and allgovernmental agencies and instrumentalities (local, state, federal or foreign) to release any information, files or recordsrequestedbytheBoardorCommittee.

Icertifythattheforegoingstatementsmadebymearetrue.Iamawarethatifanyoftheforegoingstatementsmadebymearewillfullyfalse,Iamsubjecttopunishment.

__________________________________________________________ _________________________________ SignatureofapplicantDate

Rev.1/2/19

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Sleep Studies to Qualify for a License as a Technologist

Iattestthat__________________________________________________hascompleted_____________________(Nameofapplicant)(Numberofstudies)

sleepstudiesasalicensedpolysomnographictechnicianoverthelast______________________monthsbeginning (Numberofmonths)

________________ending_______________at_____________________________________________________,(Month,Day,Year)(Month,Day,Year)(Nameoffacility)

______________________________________________________________,______________________________,(Address,City,ZIPCode)(Telephonenumber)

whichisprovisionallyorfullyaccreditedbytheAmericanAcademyofSleepMedicine(A.A.S.M.).

_______________________________________________Printnameoflicensedpolysomnographytechnologistorqualifiedmedicaldirector

_______________________________________________ ____________________________________Signatureoflicensedpolysomnographytechnologist Date(Month,Day,Year)orqualifiedmedicaldirector

_______________________________________________ ____________________________________Licensenumberoflicensedpolysomnographytechnologist Dateoflicenseexpiration(Month,Day,Year)orqualifiedmedicaldirector

Please note:

N.J.A.C. 13:44L-1.2definesa“qualifiedmedicaldirector”asalicensedphysicianwhoiseithereligibleforboardcertificationorisboardcertifiedinsleepmedicinebytheAmericanBoardofSleepMedicine,oracertificationboardrecognizedbytheAmericanBoardofMedicalSpecialtieswhichbasesitscertificationinsleepmedicineuponthesleepmedicineexaminationcreatedbytheAmericanBoardofInternalMedicine,andwhoactsasthemedicaldirectorofany:

1. In-patientorout-patientsleepcenterorlaboratoryprovisionallyaccreditedorfullyaccreditedbytheA.A.S.M.or accreditedbyJointCommission; 2. AmbulatorycarefacilityorgeneralacutecarehospitallicensedbytheDepartmentofHealth; 3. Homehealthagencies,assistedlivingresidences,comprehensivepersonalcarehomes,assistedlivingprograms andalternatefamilycaresponsoragencieslicensedbytheDepartmentofHealth;or 4. HealthcareservicefirmsregisteredwiththeDivisionofConsumerAffairs.

N.J.A.C. 13:44L-2.3(a)requiresthatalicensedpolysomnographictechnicianapplyingforalicenseasapolysomnographictechnologistcompleteatleast50sleepstudiesinoneormorefacilitiesthatareprovisionallyorfullyaccreditedbytheA.A.S.M.duringaperiodthatwasatleasttwomonthslongwithinthepreviousyear.If you have completed these sleep studies in more than one facility, submit one form for each facility.

(Attach additional copies as necessary.)

Page9of14Rev.10/14




Verification of Hospital/Medical Employment, Privileges or Appointment

Applicant’sName:_____________________________________________________________________________________________

NameofHospital/Facility:___________________________________________________________________________________________Hospital/FacilityAddress:___________________________________________________________________________________________Hospital/FacilityTelephoneNumber:__________________________________________________________________________________1. Whatpositiondidthishealthpractitionerholdatyourfacility?______________________________________________________2. Whatwerethishealthpractitioner’sdatesofemploymentatyourfacility?_____________________________________________

3. Wasthishealthpractitioneronprobation,suspended,sanctionedorinanyway sanctioned/disciplinedwhileatyourfacility? Yes No

4. Wasthishealthpractitionergrantedaleaveofabsencewhileemployedat yourfacility? Yes No

5. Wereanyrestrictionsplacedonthishealthpractitioner’sactivitieswhichwere notplacedonallotheremployeesholdingsimilarpositions? Yes No

6. Wereanyrestrictionsplacedonthishealthpractitioner’sprivileges? Yes No

7. Wereanyformalpatientorstaffcomplaintsfiledagainstthishealthpractitioner? Yes No

8. Wereanyincidentreportsfiledinvolvingtheprofessionalconductorbehaviorof thishealthpractitioner? Yes No

9. Wasthishealthpractitionereversubjecttononroutinemonitoringwhileinyourfacility? Yes No

10.Wasthishealthpractitionerinvoluntarilyremovedfromacallscheduleforcause? Yes No

11.Wasthishealthpractitionereversubjecttononroutinequalityassessmentreview? Yes No

12. Wasthishealthpractitionerthesubjectofanegativereviewbyaqualityassurance ordepartmentalcommittee? Yes No

13. Wasthishealthpractitionerthesubjectofaninvestigationbyyourfacilityorany committeeordepartmentofyourfacility? Yes No

14. Wereanymalpracticeactionsfilednamingthishealthpractitionerasadefendantthat involvedhisorherperiodofemploymentatyourfacility? Yes No

Ifyouhaveanswered“Yes”toanyofthequestionsabove,pleaseexplain:______________________________________________ _________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

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15. Didthishealthpractitionerleaveyourfacilityingoodstanding? Yes No

16. Wouldyouconsiderre-hiringthishealthpractitionerforapositionatyourfacility? Yes No

17. Wouldyourecommendthishealthpractitionerforprivilegesatyourfacility? Yes No

Ifyouhaveanswered“No” toquestions15,16or17,pleaseexplain:________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

18. Please supply any additional comments or information that theBoard should consider prior to determining this applicant’s eligibilityforlicensure.

_________________________________________________________________________________________________________

Print the name and title of certifying official:_____________________________________________________________________Signature of certifying official:______________________________________________________________________Dateformwascompleted:_________________________________________________________

NOTE: Please attach letterhead or a business card from the facility where the applicant worked or supply some form of identification for the individual supplying information.

PLEASE RETURN DIRECTLY TO:

State Board of Polysomnography124 Halsey Street, 6th Floor,

P.O. Box 45051Newark, New Jersey 07101

SEAL OF HOSPITAL(IfApplicable)

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License/Certification

Verification Request

Directions:Completeonlythetopportionofthislicense/certificationformandforwardittothelicense/certificationagencyinthestateinwhichyouarelicensed/certified.TheagencyshouldcompletetheformandreturnittotheStateBoardofPolysomnography.Note:Beadvised that theagencycompleting the formmaychargea fee for license/certificationverification.Pleasecalltheagencytocheckonfeesforlicense/certificationverificationpriortosubmittingthisform.

Name:_______________________________________________________________________________________ FirstName MiddleName LastName MaidenName,ifapplicable

Nameonoriginallicense/certification:__________________________ Telephonenumber:___________________ (includeareacode)

Currentaddress: _______________________________________________________________________________ Street City State ZIPcode

License/Certificationnumber:_______________________________Yearissued: _______________

Thissectionistobecompletedbythestatelicensing/certificationagency.

1. License/Certification number: __________________________Date issued: ____________________________

2. When was the license/certificate last renewed? ____________________________________________________

3. Is the license/certificate in good standing? Yes No

4. Has this license/certification ever been revoked, suspended or voluntarily surrendered or has any action been taken by your agency against this licensee? Yes No If“Yes,”pleaseprovideadescriptionofthereasonand/orcharge(s)andanyaction(s)takenandprovideacopy ofanycomplaint,orderorrelevantdocument.

________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

IcertifythatthestatementscontainedhereinaretruebaseduponofficialrecordsthatIreviewed.

Print Name _____________________________________________________________________

Signature _______________________________________________________________________Title ___________________________________________________________________________State ________________________________Date______________________________________

Official

SealPage12of14




Military Service Profile CompletedthisformifyouwouldliketheBoardtoconsidertheeducation,trainingoeexperienceyoureceived whileservingasamemberoftheArmedForcestowardsfulfillingtherequirementsforlicensure.

Applicant’sname:___________________________________________________________________________

Applicant’srank:___________________________________________________________________________

Branchofservice:___________________________________________________________________________

Youareherebyauthorizedtoreleaseanyinformationinyourfiles,favorableorotherwise,directlytotheState Board of Polysomnography, 124 Halsey Street, 6th Floor, P.O. Box 45051, Newark, New Jersey 07101. Please includeacopyoftheapplicant’sVerificationofMilitaryExperienceandTraining(VMET)Form2586,orany successorform,andtheapplicant’sJointServicesTranscriptdetailingtheeducation/trainingtheapplicantreceived whileinthemilitary.Yourearlyattentionisappreciated.

________________________________________________________________________ Applicant’ssignature Date

1. Whatpositionandrankdoesthisindividualholdordidhe/sheholdwhendischarged?

_____________________________________________________________________________________

_____________________________________________________________________________________

2. Whatwerethisindividual’sdatesofservice?__________________________________________________

3. Whattypeofdischargedidthisindividualreceive?____________________________________________

A.Whatwasthedateofdischarge?________________________________________________________

4. Wastheindividualonprobation,suspendedorinanywaysanctioned/disciplinedwhileinthemilitary? Yes No

5. Wasthisindividualgrantedaleaveofabsencewhileinthemilitary? Yes No

6. Wereanyrestrictionsplacedonthisindividual’sactivitieswhichwerenotplacedonallotherpersonnel holdingsimilarpositions? Yes No

7. Wouldthisindividualberecommendedforre-enlistment? Yes No If“No,”pleaseexplain._________________________________________________________________

____________________________________________________________________________________

8. Wouldthisindividualberecommendedforpromotion? Yes No

If“No,”pleaseexplain._________________________________________________________________

____________________________________________________________________________________Page13of14

9. Didqualityassessmentreviewofthisindividualeverresultinanegativefinding? Yes No If“Yes,”pleaseexplain._________________________________________________________________

_____________________________________________________________________________ 10. WasthisindividualintheMedicalCorps? Yes No If“Yes,”pleaseanswerquestionsA-H:

A.Wasthisindividualdeniedclinicalprivilegeswhileinthemilitary? Yes No

B. Wereanyrestrictionsplacedonthisindividual’sclinicalprivileges? Yes No

C. Wereanyformalpatientorstaffcomplaintsfiledagainstthisindividual? Yes No

D.Wereanyincidentreportsfiledinvolvingtheprofessionalconductorbehavior ofthisindividual? Yes No

E. Wasthisindividualeversubjecttononroutinemonitoringwhileinthe militaryservice? Yes No

F. Wasthisindividualremovedfromacallscheduleforcause? Yes No

G.Wasthisindividualsubjecttononroutinequalityassessmentreview? Yes No

H.Wouldyourecommendthisindividualforprivilegesatahospital? Yes No

PleasesupplyanyadditionalcommentsorinformationthattheBoardorCommitteeshouldconsiderpriorto determiningthisapplicant’seligibilityforlicensure.

_________________________________________________________________________________________

_________________________________________________________________________________________

Pleaseprintthenameoftheindividualsupplyingtheinformation:____________________________________

Signatureoftheindividualsupplyingtheinformation:_____________________________________________ Addressandfulltelephonenumberwheretheindividualsupplyingtheinformationmaybecontacted:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Dateformwascompleted:___________________________________________________

Please return directly to: State Board of Polysomnography 124HalseyStreet,6thFloor P.O.Box45051 Newark,NJ07101

Please Affix

OfficialSeal Here

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Polysomnography Technologist-Holder of a ......Verification of RPSGT Credentials 2. Please arrange...

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