Examining Board Of Physical Therapists And Athletic Trainers Page 6
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12DISCLOSURES
14. Have you ever been convicted of or entered a plea of guilty or nolo contendere (no contest) to any felony,
misdemeanor or any other criminal offense in any jurisdiction, including any offense for which you have received a
pardon?
Yes
No
If yes, submit a signed statement explaining fully.
Arrange for the Board office to receive State of Delaware and Federal Bureau of Investigation criminal
background checks. The State Bureau of Identification will send the reports directly to the Board office. This
requirement applies even if you answered “No” to this question.
15. Are criminal charges pending against you in any jurisdiction? Yes
No
If yes, submit a letter explaining fully.
Include copies of all appropriate records.
16. Has your license ever been revoked or suspended or has any other disciplinary action been taken by the authorities of
another jurisdiction (including any state, D.C., U.S. territory or other country)? Yes
No
If yes, enclose a
statement explaining fully. Include any relevant documents.
17. Is any complaint or disciplinary action pending against your license in any other jurisdiction? Yes
No
If yes,
enclose a statement explaining fully. Include any relevant documents.
18. Has your application for a license or registration ever been refused or denied in any other jurisdiction? Yes
No
If yes, enclose a statement explaining fully. Include any relevant documents.
19. Are you now, or have you ever been, dependent on the use of alcohol, stimulants, or habit-forming drugs?
Yes
No
If yes, enclose a statement explaining fully. Include any relevant documents.
DUTY TO REPORT
20. To obtain a license in Delaware, you must certify that you understand that you have a mandatory obligation to file a
written report with the Board of Medical Licensure and Discipline within 30 days if you have any reason to believe that
a medical practitioner other than yourself is (or may be) guilty of unprofessional conduct as defined in 24 Del. C. §1731
OR that he/she is (or may be):
•
medically incompetent
•
mentally or physically unable to engage safely in the practice of medicine
•
excessively using or abusing drugs including alcohol.
I certify that I have read and understand the provisions of
24 Del. C. §1730, 24 Del. C. §1731 and 24 Del. C. §1731A
and that I understand my duty to report. Yes
No
21. To obtain a license in Delaware, you must certify that you understand that you have a mandatory obligation to make
an immediate oral report to the Department of Services for Children, Youth and Their Families if you know of, or you
suspect, child abuse or neglect under Chapter 9 of Title 16 and to follow up with any requested written reports.
I certify that I have read and understand
16 Del. C. §903
and that I understand my duty to report. Yes
No
22. To obtain a license in Delaware, you must certify that you understand that you have a mandatory obligation to file a
report with the Division of Professional Regulation if you have knowledge that another PT, PTA or AT licensee has
violated the Board’s Code of Professional Conduct in Section 12.0 of its
Rules and Regulations
or has violated any
other Delaware law or rule pertaining to physical therapy or athletic training.
I certify that I have read and understand
Section 12.23
of the Board’s Rules and Regulations and that I understand my
duty to report. Yes
No
If Board review is required, the Board office must receive all of these items no later than 4:30 PM ten full
working days before the Board’s meeting date:
•
Completed, signed and notarized application form
•
Fee payment
•
All required supporting documentation.
Applications that are not complete within 12 months of filing may be considered abandoned and discarded.
When your application is complete, please allow 4-8 weeks to receive your license.
Revised 6/2016
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