Free 50819.FH11 - Indiana

APPLICATION FOR STUDENT PERMIT TO PRACTICE RESPIRATORY CARE
State Form 50819 (R / 2-06) Approved by State Board of Accounts, 2006

INSTRUCTIONS:

Please type or print all information.

RESPIRATORY CARE COMMITTEE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected] www.pla.IN.gov

* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given.

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER STUDENT PERMIT NUMBER STUDENT PERMIT ISSUE DATE (month, day, year) STUDENT PERMIT EXPIRATION DATE (month, day, year) DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City Date of birth (month, day, year) Telephone number (daytime) State Place of birth (city and state or country) Email address ZIP code Social Security number *

APPLICANT Attach one (1) passport type quality photograph of yourself taken within the last eight weeks.

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BASIS OF APPLICATION (please check one) New applicant - applying for the first time for a student permit Change of hospital or facility of employment Additional hospital or facility employment - adding an additional hospital or facility of employment Change of respiratory care procedures - adding additional procedures the student permit holder may provide Transfer of school Change of graduation date Do you hold or have you ever held a student permit? If yes, please list student permit number(s).

Yes

No

NAME OF SCHOOL

SCHOOL OR PROGRAM OF RESPIRATORY CARE CURRENTLY ENROLLED LOCATION OF SCHOOL DATE ENTERED DATE OF EXPECTED GRADUATION

NAME OF SCHOOL

OTHER SCHOOLS OR PROGRAMS ATTENDED LOCATION OF SCHOOL

DATES ATTENDED

DEGREE GRANTED

Do you hold or have you ever held, a license, certificate, registration or permit to practice any regulated health occupation? If yes, please explain in the space located below.

Yes

No

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LIST ALL PLACES YOU HAVE LIVED SINCE ENROLLING IN YOUR SCHOOL OR PROGRAM GENERAL LOCATION

DATES

LIST ALL PLACES WHERE YOU HAVE BEEN EMPLOYED TO PRACTICE RESPIRATORY CARE PRIOR TO APPLYING FOR A STUDENT PERMIT ADDRESS DATES OF EMPLOYMENT EMPLOYER

If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. Letters from attorneys are not accepted in lieu of your statement. Falsification of any of the following, is grounds for permanent revocation of a permit issued pursuant to this application. 1. Have you ever previously filed an application in the State of Indiana? 2. Has disciplinary action ever been taken regarding any license, certificate, registration or permit you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit to practice respiratory care or any regulated health occupation in any state (including Indiana) or country? 4. Are you now being, or have you ever been treated for drug or alcohol abuse? 5. Have you ever been convicted of, pled guilty or nolo contendere to: A. A violation of any Federal, State, or local law relating to the use, manufacturing, distribution or dispensing of controlled substance or drug addiction? B. Any offense, misdemeanor or felony in any state? (Except for minor traffic laws resulting in fines.) 6. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? 7. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date signed (month, day, year)

Yes Yes Yes Yes

No No No No

Yes Yes Yes Yes

No No No No

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of their authorized representatives in connection with processing my application for a student permit to practice repertory care. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same. AFFIRMATION Signature of applicant

Date signed (month, day, year)

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I understand the following as a holder of a student permit: I shall meet in person at least one (1) time each working day with my supervising practitioner or a designated respiratory care practitioner to review the permit holders clinical activities. The supervising practitioner or a designated respiratory care practitioner shall review and countersign the entries that the permit holder makes in the patients medical record not more than seven (7) calendar days after the permit holder makes the entries. I may only perform procedures that I have successfully completed and documented in the respiratory care program, AND that the Committee has approved and are on file at the Professional Licensing Agency. The procedures permitted may be performed ONLY on adult patients who are not critical care patients and under the proximate supervision of a licensed respiratory care practitioner. This means that the student permit holder may not perform blood gas sampling and analysis, work in ICU, ER, or Pediatrics. The student permit holder, working under the student permit, MAY NOT perform blood gas sampling and analysis, work in ICU, ER, and Pediatrics after graduation. The new graduate may work in the above-mentioned areas ONLY after applying for AND receiving a temporary permit, as described above. A student permit expires on the earliest of the following: The date a student permit holder is issued a respiratory care license or temporary permit. The date the Committee disapproves the student permit holders application for a license. The date the student permit holder ceases to be a student in good standing in a respiratory care program. Sixty (60) days after the date that the student permit holder graduates from a respiratory care program. The date that the student permit holder is notified that he / she failed the licensure examination. Two (2) years after the date of issuance.
Signature of applicant Date signed (month, day, year)

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PART II. APPLICATION FOR A STUDENT PERMIT TO PRACTICE RESPIRATORY CARE HOSPITAL OR FACILITY OF EMPLOYMENT
(This form is to be completed by the hospital or facility where the applicant will be employed.)
NAME OF STUDENT
Name of student Social Security number *

NAME OF LICENSED RESPIRATORY CARE PRACTITIONER SUPERVISOR DESIGNEE
Name of RCP supervisor designee Respiratory care license number Telephone number Expiration date (month, day, year) Email address

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HOSPITAL OR FACILITY OF EMPLOYMENT
Name of hospital or facility Address (number and street or rural route) City State ZIP code

APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of licensed respiratory care practitioner Date signed (month, day, year)

SUPERVISION OF STUDENT PERMIT HOLDER ACCORDING TO IC 25-34.5-2-14(f) & (g): (f) A holder of a student permit shall meet in person at least one (1) time each working day with the permit holders supervising practitioner or a designated respiratory care practitioner to review the permit holders clinical activities. The supervising practitioner or a designated respiratory care practitioner shall review and countersign the entries that the permit holder makes in a patients medical record not more than seven (7) calendar days after the permit holder makes the entries. (g) A supervising practitioner may not supervise at one (1) time more than three (3) holders of student permits issued under this section. IF THE STUDENT PERMIT HOLDER LEAVES YOUR EMPLOYMENT YOU MUST NOTIFY THE RESPIRATORY CARE COMMITTEE.

Please return this application to the following address:

Professional Licensing Agency 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected]

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PART III. APPLICATION FOR A STUDENT PERMIT TO PRACTICE RESPIRATORY SCHOOL OR PROGRAM OF RESPIRATORY CARE PROCEDURES COMPLETED BY THE STUDENT PERMIT HOLDER
(To be completed by the Program Director and Director of Clinical Education of the Respiratory Care School or Program)
APPLICANT INFORMATION
Name of student Social Security number *

SCHOOL OR PROGRAM OF RESPIRATORY CARE
Name of school or program Date of admission (month, day, year) Address (number and street or rural route) City Name of program director Telephone number Email address State ZIP code Date of expected graduation (month, day, year)

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Name of program director of clinical education Telephone number Email address

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AFFIRMATION I hereby swear or affirm that the applicant is a student in good standing in a program or school of respiratory care which is approved by the Indiana Respiratory Care Committee and the applicant has successfully completed the list of procedures which is attached to this application.
Signature of program director Signature of program director of clinical education Date signed (month, day, year) Date signed (month, day, year)

The program director or director of clinical education must notify the Indiana Respiratory Care Committee if the student ceases to be in good standing in the respiratory care program. Failure to do so may be grounds for disciplinary action.

Please return this application to the following address:

Professional Licensing Agency 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected]

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RESPIRATORY CARE PROCEDURES Please check-off the procedures which have been a part of a course that the applicant has successfully completed in the respiratory care program and completion has been documented in both lecture and lab, and also in clinical. Please note that the procedures permitted may be performed only: (1) on adult patients who are not critical care patients; and (2) under the proximate supervision of a licensed respiratory care practitioner. PROCEDURES CHECK-OFF

1. Aerosol Medication Delivery 2. Airway Clearance Techniques 3. Capnography 4. Chest Physiotherapy 5. Completion of Basic Respiratory Pharmacology 6. Cylinders 7. Directed Cough Technique 8. EKG 9. Endotracheal Suctioning 10. Flow Meters 11. Gas Regulators 12. Humidity and Aerosol Therapy 13. Incentive Spirometry 14. Intermittent Volume Expansion 15. Liquid Systems 16. Manual Ventilation 17. Medical Records 18. Metered Dose Inhaler 19. Minute Ventilation 20. Nasotracheal Suctioning 21. Oxygen Analysis 22. Oxygen Therapy 23. Oxygen / Medical Gas Administration 24. Patient Interview and History 25. Peak Flow 26. Pharyngeal Airway Insertion 27. Physical Assessment of Chest 28. Spirometry Screening 29. Sputum Inductions 30. Tidal Volume 31. Tracheostomy Care 32. Transutaneous Monitors 33. Standard Precautions 34. Vital Capacity 35. Vital Signs
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