Form Doh 662-097 - Optometrist License Application Packet (Page 8 of 27) in pdf

2. Personal Data Questions

Yes No

1. Do you have a medical condition which in any way impairs or limits your ability to practice your

profession with reasonable skill and safety? If yes, please attach explanation. ...................................... F F

“Medical Condition” includes physiological, mental or psychological conditions or

disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments,

cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes,

intellectual disabilities, emotional or mental illness, specific learning disabilities, HIV disease,

tuberculosis, drug addiction, and alcoholism.

If you answered yes to question 1, explain:

1a. How your treatment has reduced or eliminated the limitations caused by your medical condition.

1b. How your field of practice, the setting or manner of practice has reduced or eliminated the

limitations caused by your medical condition.

Note: If you answered “yes” to question 1, the licensing authority will assess the nature,

severity, and the duration of the risks associated with the ongoing medical condition

and the ongoing treatment to determine whether your license should be restricted,

conditions imposed, or no license issued.

The licensing authority may require you to undergo one or more mental, physical or

psychological examination(s). This would be at your own expense. By submitting this

application, you give consent to such an examination(s). You also agree the

examination report(s) may be provided to the licensing authority. You waive all claims

based on confidentiality or privileged communication. If you do not submit to a

required examination(s) or provide the report(s) to the licensing authority, your

application may be denied.

2. Do you currently use chemical substance(s) in any way which impair or limit your ability to

practice your profession with reasonable skill and safety? If yes, please explain. .................................. F F

“Currently” means within the past two years.

“Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally.

3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or

frotteurism? .............................................................................................................................................. F F

4. Are you currently engaged in the illegal use of controlled substances? .................................................. F F

“Currently” means within the past two years.

Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine)

not obtained legally or taken according to the directions of a licensed health care practitioner.

Note: If you answer “yes” to any of the remaining questions, provide an explanation and

certified copies of all judgments, decisions, orders, agreements and surrenders. The

department does criminal background checks on all applicants.

5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had

prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? .. F F

Note: If you answered “yes” to question 5, you must send certified copies of all court

documents related to your criminal history with your application. If you do not

provide the documents, your application is incomplete and will not be considered.

If you have been granted certificate(s) of restoration of opportunity, please

provide a certified copy of each certificate.

To protect the public, the department considers criminal history. A criminal history

may not automatically bar you from obtaining a credential. However, failure to report

criminal history may result in extra cost to you and the application may be delayed

or denied.

DOH 662-092 April 2017

Page 2 of 5

Form Doh 662-097 - Optometrist License Application Packet Page 8

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