State Form 46715 - Application For Athletic Trainers License (Page 6 of 7) in pdf

State Form 46715 - Application For Athletic Trainers License Page 6

VERIFICATION OF SUPERVISION

Applicants applying for a temporary permit, who have not taken the NATABOC examination, must practice under the supervision of an

athletic trainer who is licensed by the State of Indiana during the ninety (90) days in which the temporary permit is valid.

Applicants must forward this form to the licensed athletic trainer who will be supervising the applicant. The form must be completed,

notarized and submitted to the Health Professions Bureau by the qualified supervisor.

This is to verify that

will be under my supervision while practicing athletic

training. According to Indiana Code 25-5.1-3-8 (b), 898 IAC 1-1-9 and 898 IAC 1-4-1, I understand that I shall be available and under all

circumstances shall be absolutely responsible for the direction and the actions of the person supervised when services are performed. I

understand that the patients care shall always be my responsibility. I also understand that it is my responsibility to maintain records of

experiential hours for the person being supervised.

Beginning date (month, day, year)

Signature of supervisor

Name of setting where supervision will occur

Printed name of supervisor

Address of setting where supervision will occur

Indiana license number of the supervisor

Date (month, day, year)

Telephone number

SEAL OF NOTARY PUBLIC

MAIL COMPLETED FORM TO:

HEALTH PROFESSIONS BUREAU

402 WEST WASHINGTON STREET, ROOM 041

INDIANAPOLIS, IN 46204

TEMPORARY PERMITS ARE NOT AVAILABLE ON A WALK-IN PASIS.

NOTE: According to IC 25-5.1-3-8, a temporary permit expires the earlier of: (1) the date the person holding the permit is issued a license;

(2) the date the Board disapproves the person’s application of licensure; or (3) ninety (90) days after the date of issuance of the temporary

permit.

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State Form 46715 - Application For Athletic Trainers License Page 6