Free 53462.FH11 - Indiana

APPLICATION FOR CHIROPRACTIC GRADUATE STUDENTS
State Form 53462 (1-08)

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INDIANA BOARD OF CHIROPRACTIC EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected]

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

FOR OFFICE USE ONLY
Number issued Date of issuance (month, day, year) Program start date (month, day, year) Program end date (month, day, year)

DO NOT WRITE ABOVE THIS LINE
THIS SECTION TO BE COMPLETED BY THE GRADUATE STUDENT
Name of graduate student (last, first, middle/maiden) Address (number and street or rural route number, city, state, and ZIP code) Telephone number (daytime) E-mail address Date of birth (month, day, year) Place of birth Social Security number *

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Name of chiropractic school Beginning date of graduate program with a licensed chiropractor (month, day, year)

Expected date of graduation (month, day, year) Ending date of graduate program with a licensed chiropractor (month, day, year)

I have reviewed the requirements set forth in 846 IAC 1-10 and understand that I may not provide an independent diagnosis of a patient and must maintain a log of chiropractic procedures that shall be reviewed daily by the supervisor and shall be available for review by the Board at the Boards request.
Signature of graduate student Date (month, day, year)

THIS SECTION TO BE COMPLETED BY THE SUPERVISOR OF THE GRADUATE STUDENT
Name of supervisor (last, first, middle/maiden) Address (number and street or rural route number, city, state, and ZIP code) Name of practice Telephone number (daytime) E-mail address Date of birth (month, day, year) Date of expiration (month, day, year) Social Security number *

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Indiana license number

I am aware of the requirements set forth in 846 IAC 1-10 and understand that I will be exclusively responsible for the direct supervision of the chiropractic graduate student who is completing the graduate program.
Signature of supervisor Date (month, day, year)

RULE 10 - GRADUATE STUDENTS
846 IAC 1-10-1, Graduate students Authority: IC 25-10-1-1.5 Affected: IC 25-10-1-14 Section 1. For the purposes of this rule, the following definitions apply: (1) Graduate student means a student in the final year of course work at a chiropractic school or college provided by IC 25-10-1-2 (a). (2) Supervisor means a chiropractor licensed under IC 25-10 who will act as the direct supervisor and overseer of the educational process for the graduate student. (Board of Chiropractic Examiners, 846 IAC 1-10-1) 846 IAC 1-10-2, Applications of graduate students Authority: IC 25-10-1-1.5 Affected: IC 25-10-1-14 Section 2. A graduate student shall submit the following information: (1) Certification from the school that the applicant is enrolled in the final year of coursework; (2) An application approved by the Board and provided by the Bureau including, but not limited to, the following information: (a) the location of the practice of the supervisor, (b) the proposed dates of practice by the graduate student, (c) the name and license number of the supervisor. 846 IAC 1-10-3, Duties of graduate students Authority: IC 25-10-1-1.5 Affected: IC 25-10-1-14 Section 3. (a) A graduate student shall not provide an independent diagnosis for a patient. (b) A graduate student shall maintain a log of chiropractic procedures that shall be reviewed daily by the supervisor and shall be available for review by the Board at the Boards request. (Board of Chiropractic Examiners, 846 IAC 1-10-3) 846 IAC 1-10-4, Duties of supervisors Authority: IC 25-10-1-1.5 Affected: IC 25-10-1-14 Section 4. (a) The supervisor of a graduate student shall hold an Indiana chiropractic license which is current and in good standing. (b) A supervisor shall supervise no more than one (1) graduate student at any given time. (c) The supervisor shall develop a training schedule in coordination with the school or college of chiropractic that will be followed by the graduate student throughout the educational process. (d) Chiropractors who supervise graduate students shall be exclusively responsible for the direct supervision of the graduate students. (e) Upon successful completion of the educational program, the supervisor shall provide the Board with a letter stating that the graduate student has completed the program from the beginning date to the ending date. (Board of Chiropractic Examiners, 846 IAC 1-10-4. Filed November 15, 1990.)