Application For An Optometry License - New Jersey State Board Of Optometrists Page 5
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137. Medical Conditions Questions
Questions a through f pertain to medical conditions and use of chemical substances. Please read the definitions carefully.
Your responses will be treated confidentially and retained separately. Please be aware that you have the right to elect not to
answer those portions of the following questions which inquire as to the illegal use of controlled dangerous substances or
activity if you have reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In
that event, you may assert the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege
must be made in good faith. If you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond
to all other questions on the application. Your application for licensure or certification will be processed if you claim the
Fifth Amendment privilege against self-incrimination. You should be aware, however, that you may later be directed by the
Attorney General to answer a question that you have refused to answer on the basis of the Fifth Amendment, provided that
the Attorney General first grants you immunity afforded by statutory law. (N.J.S.A. 45:1-20.)
“Ability to practice as an optometrist” is to be construed to include all of the following:
a. The cognitive capacity to exercise the reasonable judgments of an optometrist, and to learn and keep abreast of
professional developments; and
b. The ability to communicate those judgments and related information to patients and other interested parties, with or
without the use of aids or devices, such as voice amplifiers; and
c. The physical capability to perform the duties of an optometrist, with or without the use of aids or devices, such as
corrective lenses or hearing aids.
“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, mental retardation, emotional or mental illness, specific learning disabilities, H.I.V. disease,
tuberculosis, drug addiction and alcoholism.
“Chemical substance” is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid
prescription for legitimate medical purposes and in accordance with the prescriber’s direction, as well as those used illegally.
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application.
Rather, it means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee,
or within the previous two years.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g.
heroin or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid
prescription or not taken in accordance with the directions of a licensed health care practitioner.
a. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with
reasonable skill and safety?
Yes
No
b. Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing
treatment (with or without medications) or participate in a monitoring program**?
Yes
No
Not applicable
c. Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the field of
practice, the setting or manner in which you have chosen to practice?
Yes
No
Not applicable
d. Does your use of chemical substance(s) in any way impair or limit your ability to practice your profession with reasonable
skill and safety?
Yes
No
Not applicable
e. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism or voyeurism?
Yes
No
f.
Are you currently engaged in the illegal use of controlled dangerous substances? (Recall that “currently” is defined as
“within the last two years.”)
Yes
No
If you answered “Yes” to question f, are you currently participating in a supervised rehabilitation program or professional
assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled
dangerous substances?
Yes
No
** If you receive such ongoing treatment or participate in such a monitoring program, the Board will make an individualized
assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to determine
whether an unrestricted license or certificate should be issued, whether conditions should be imposed or whether you are
not eligible for licensure or certification.
_________________________________________________
___________________________________
Signature of applicant
Date
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