STATE OF FLORIDA BOARD OF MASSAGE THERAPY APPLICATION FOR LICENSURE

STATE OF FLORIDA BOARD OF MASSAGE THERAPY APPLICATION FOR LICENSURE WITH INSTRUCTIONS Board of Massage Therapy 4052 Bald Cypress Way, Bin # C-06 Tallahassee, FL 32399-3256 (850) 488-0595 www.doh.state.fl.us/mqa/massage/ma_home.html Charlie Crist Governor Revised November 2007 Ana M. Viamonte Ros, M.D., M.P.H State Surgeon General TABLE OF CONTENTS Section I: Section II: Section III: General Information/Instructions Application Criminal Conviction Form/Instructions υ υ υ υ υ υ υ υ υ ATTENTION υ υ υ υ υ υ υ υ υ υ • Please retain the application instructions for your records. Do not send them to the Board Office with your application. • Make a copy of everything you send to the Board Office. You may need to reference it during the application process. • Read all instructions thoroughly before completing the application. • Mail the completed ORIGINAL application and fees to the department at the address noted in the instructions • Keep a copy of the completed application for your records. • Read the entire application package. Most questions will be answered by reading the enclosed instructions, application, and supplemental documentation forms. 1 SECTION I: GENERAL INFORMATION / INSTRUCTIONS Please read the following COMPLETELY before attempting to complete the application, as this information is provided to assist you in expediting the application process. APPEARANCES Certain applicants may be required to appear before the Board to discuss their application or may be referred to the Professionals Resource Network (PRN) for an evaluation of competency to practice before a determination of licensure can be made. An appearance, PRN referral or combination of both may be required for a variety of reasons, such as (but not limited to): ▪ Criminal Convictions ▪ Previous Discipline ▪ Previous appearance before a licensing board or regulatory agency ▪ Drug/alcohol addiction/impairment ▪ Discrepancies in application information/materials ▪ Participation in an impaired practitioner program ▪ Other reasons as deemed necessary by Board staff or the Board Chair The scenarios listed above are not an automatic appearance before the Board or PRN referral. Appearances and PRN referrals are determined on an individual basis. The Board’s History Liaison, not office staff, determines the necessity of an appearance/referral. The History Liaison, at his/her discretion, may also require an application be presented to the Board for review, but not require the appearance of the applicant. Should your appearance or referral be required, you will be notified in writing. In the event that you feel you might be required to appear or be referred to PRN based on the scenarios listed above, it is imperative that you adhere to the deadlines listed below. The Board only meets quarterly; therefore in order for your application to be considered by the Board, you MUST have your application in the Board Office by the deadline dates listed below. Because applications are often deemed incomplete upon initial review, which may take up to 30 days, it is recommended that you submit your application at least sixty (60) days prior to the meeting for which application is made. The deadline for COMPLETION of your application is no less than 5 weeks prior to the Board’s meeting. Note: if you are referred to PRN for an evaluation, your licensure recommendation (from PRN) would need to be in the Board office by the completion deadline in order to be presented to the Board at that meeting. The evaluation process can take several weeks so please plan accordingly. It is very important that you understand the necessity of these dates. These dates and deadlines are published so that you may make licensure plans accordingly. Please refrain from making any commitments or accepting positions to practice massage therapy in Florida, as exceptions and/or special accommodations can not be made. It is IMPERATIVE that you adhere to the dates that are listed for your convenience. YEAR 2008 MEETING SCHEDULE (Dates/locations are subject to change) Required Application Meeting Date COMPLETION Deadline January 24-25, 2008 December 17, 2007 April 23-25, 2008 March 17, 2008 July 24-25, 2008 June 17, 2008 October 30-31, 2008 September 22, 2008 2 REQUIREMENTS FOR LICENSURE BY ENDORSEMENT In order to qualify for licensure by endorsement you must meet the following criteria: 1. You must hold a current and valid license to practice massage therapy in another state. 2. That license must have been issued upon graduation from a massage therapy school approved by that state. 3. That license must have been issued upon passage of one of the exams offered by the National Certification Board for Therapeutic Massage and Bodywork. In addition to the above, you must also submit the following: 1. An Application for Licensure and appropriate fees. 2. An official transcript from your original massage therapy school. Please be advised that an official transcript must include your dates of attendance, grades in all courses, number of hours in each course, an official seal and original signature. If you are unable to provide us with the above, you may be required to appear before the Board for further determination of licensure. 3. An official license verification from all states where you hold a massage therapy OR other health care license. Please note that the verification from the state which you are endorsing from must include the following: the date of original licensure, the method of licensure (i.e.- national exam, state exam, grandfather, etc.) and if you have ever been disciplined. 4. You must complete a Florida Laws and Rules course at a Florida Board Approved School. Note- This cannot be obtained through a continuing education. It must be done in a classroom setting at an approved school. 5. You must complete a 3 hour course on HIV/AIDS (if not done as a part of your original training). If you completed this course in your original training, the course must be clearly denoted on the official transcript. This can be done at a board approved school or through the Red Cross. 6. You must complete a 2 hour course on the Prevention of Medical Errors. This can be done at through a board approved school or a board approved continuing education provider. 7. Any additional information that is required as a part of the application process. 3 Where to send the application: to the following: The original application accompanied by the applicable fee should be addressed Department of Health Payment Management P.O. Box 6330 Tallahassee, FL 32399-6330 Use of the above address will ensure receipt of the application and fee(s). Where to send any additional documentation: Any additional documentation, sent either by the applicant or by any other source on your behalf, should be mailed to the following address: Board of Massage Therapy 4052 Bald Cypress Way, BIN C06 Tallahassee, FL 32399-3256 DOCUMENTATION REQUIRED No application will be considered complete until the following supporting documentation has been received in the Board office: • • • Application - A completed application, with all questions answered. Failure to provide an answer to every question will result in the application being deemed incomplete. Photo - One current photograph of the applicant Transcripts - An official transcript from a Massage Therapy school approved by the Florida Board of Massage Therapy or completion of a Board Approved Apprenticeship program. Please request your massage therapy school or the sponsor of your apprenticeship program to submit your transcript or apprenticeship verification form, whichever is applicable to the “additional documentation” address listed above. If you did not attend a Florida Board Approved Massage Therapy School, you may have your previous massage therapy education evaluated by an approved school by taking your transcript and the enclosed Transfer of Credit Form to an approved school for evaluation. Once your transcript has been evaluated and the Florida Board approved school determines you meet the education requirement pursuant to 64B7-32.003, F.A.C., you may submit your application for licensure along with your officially completed Transfer of Credit Form (which can be obtained from the Board Approved School). Medical Errors - Proof of completion of a Board approved (2) hour Medical error prevention course. If the course is not reflected on your school transcript then you must submit verification separately. If you have questions as to whether you completed these courses, please contact your school. Exam - Proof of passage of the National Certification Examination for Therapeutic Massage and Bodywork (NCETMB). Candidates for licensure must apply directly to NCBTMB by calling 1-800-296-0664 to request an application. The fee for the examination, which is $225.00, should be paid directly to NCBTMB. Exam scores for Florida candidates only will be electronically submitted to the Florida Board of Massage Therapy. If you are not a Florida resident when sitting for the exam, you must have your scores mailed directly from NCBTMB to the Board office using the “additional documentation” address listed above. Important – The State of Florida only accepts the National Certification Exam for Therapeutic Massage and Bodywork at this time. License Verification - You must also request an official license verification(s) to be submitted to the Board directly from all State licensing Boards in which you hold/held any healthcare or massage therapy license. Name Change Documentation - If you have legally changed your name through marriage or action of the court you must submit all names in which you have been known and submit a copy of a marriage or divorce decree or other court document reflecting the legal name change. Military Documentation – If you have ever been in the United States Military, please provide a copy of your DD214 or a copy of your current orders. If you have ever been sanctioned by the military or received a dishonorable discharge, you must also submit a letter explaining the sanction and documentation form the military regarding the sanction and any action taken as a result. Other - Additional documentation may be required or requested based on affirmative answers to certain questions on the application. This is noted next to the corresponding question in the application. • • • • • • APPLICATION FEES: Make cashiers check or money order payable to the Department of Health Initial Licensure: $205.00 ($50 application fee (non- refundable), $150 initial license & $5- Combat Unlicensed Activity) 4 Do Not Write In This Space Office Use Only Massage Therapy Application Client 1401 State Of Florida Application for Massage Therapist Licensure Board of Massage Therapy PO Box 6330 Tallahassee, Florida 32399-6330 (850) 488-0595 1. Select Application Category: Licensure by Exam Licensure by Endorsement Date of National Exam 2. Would you be willing to provide health services in special needs shelters or to help staff disaster medical assistance teams during times of emergency or major disasters? (First) (Middle Initial) (Last) 3. Name: 4. Social Security Number (Required): 5. Mailing Address: (Street number & Name) (City , State & Zip Code) Yes No 6. Physical Address (Street number & Name) (City , State & Zip Code) (Home Phone Number) (Business Phone Number) 7. Phone Numbers: 8. Have you ever changed your name through marriage or through action of a court, or have you ever been known by any other name? If yes, list name(s) and date(s) of name change(s): Yes No 9. We are required to ask that you furnish the following information as part of your voluntary compliance with Section 2, Uniform Guidelines on Employee Selection Procedure (1978) 43 FR38296 (August 25, 1978). This information is gathered for statistical and reporting purposes only and does not in any way affect your candidacy for licensure. Sex: Female Male Place Of Birth (City/State/Country): Date Of Birth (Month/Day/Year): Race And National Origin Native American Physical Description: Black (Color of Eyes) _____________________________ (Other Means of Identification) _______________________________________________________ Caucasian Oriental (Color of Hair) _____________________________ (Driver’s License Number) _____________________________ Hispanic Other: (Height) _____________ (Weight) _____________ 10. Are you a citizen of the United States? a. If you answered no, which Country do you hold citizenship to? _____________________________ 11. Have you ever been in the United States Military or Public Health Service? a. If “yes” list branch of service, rank and dates of service: _______________________________________________ b. Have charges ever been brought against you by any branch of the United States Armed Services? If yes, please refer to application instructions for required documentation. Yes Yes Yes No No No DH-MQA 1115, 11/07 5 12. Do you now hold or have you ever held any license (medical or professional service) or certificate of registration to practice massage therapy or any other profession, in any state, U.S. territory or foreign country? (e.g.: Nursing, Chiropractic, Facial and Skin Care Specialist, Physical Therapist, Occupational Therapist, etc.) Yes No a. If yes, list state(s), TYPE of license, license number(s), date(s) of issuance, status of license(s) and an explanation if the license is no longer active: ________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 13. Massage Therapy Diploma or certificate was obtained from: ____________________________________________________ Is this a Florida Board Approved School? Yes No Dates Attended: ________________________ Total Number of Hours Completed: ______________ 14. If you attended an Apprenticeship program: Name of Sponsor: ___________________________________________________________________________________ Total Number of Instruction Hours Completed: _____________________________________________________ APPLICANT HISTORY Please be advised that failure by the applicant to provide the supporting documentation and information, at the time the application is filed, could lead to a delay in the processing of the application, including but not limited to a required appearance before the Board, referral to PRN or any other measure authorized by law. PROFESSIONAL LICENSURE If you answer “yes” to any of questions 15-19 below, you must provide the following WITH the application at the time of submission: 1. A statement explaining in your own words the complete details as to the state(s), license number(s) and relevant circumstances. 2. A copy of all documentation from the state(s) regarding the incident, including the complaint and final action. 15. Have you ever been denied the right to take a massage therapy (or any other medical or Yes No personal service) licensing examination in any state or jurisdiction 16. Have you ever been refused a license to practice massage therapy or any other professional license - or renewal thereof- in any state or other jurisdiction? 17. Have you ever had a license or certificate of registration to practice massage therapy or any other licensed profession revoked, suspended or otherwise acted against (including probation, fine, reprimand, or surrender of a license) in a disciplinary proceeding or in response to an investigation in any state? (i.e.: Nurse, Chiropractor, Facial/Skin Care Specialist, Physical Therapist, Occupational Therapist etc.) 18. Are you now or have you ever been a defendant in a civil litigation in which the basis of the complaint against you was an alleged negligence, malpractice, or lack of professional competence, or sexual misconduct? 19. Is there currently pending against you (in any state or jurisdiction) a complaint against your professional conduct or competence? Yes No Yes No Yes No Yes No CRIMINAL HISTORY If you answer “yes” to question 20 below, you must provide the following WITH the application at the time of submission: 1. Completion of the attached Criminal History Form, on which you must provide all relevant details. 2. Certified documentation from the Clerk of Court pertaining to the arrest/charges, sentencing due to the arrest and proof of successful completion of your sentencing. 20. Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and Yes No felonies, even if the court withheld adjudication so that you would not have a record of conviction. Driving under the influence or driving while impaired is not a minor traffic offense for purposes of this question. 6 GENERAL HISTORY If you answer “yes” to any of questions 21- 24 below, you must provide the following WITH the application at the time of submission: 1. A complete description of all treatments and diagnoses you received for any condition/impairment you experienced or were treated for, including all medications prescribed and all physicians/counselors seen. 2. A statement from your treating physician/counselor for each condition you were or are being treated for, including all DSM IIIR / DSM IV, Axis I, II and III diagnoses. 21. In the last 5 years, have you been enrolled in, required to enter into, or participated in any drug Yes No or alcohol recovery program or impaired practitioner program? 22. In the last 5 years, have you been treated for or had a recurrence of a diagnosed mental disorder or impairment? 23. In the last 5 years, have you been treated for or had a recurrence of a diagnosed physical impairment? 24. In the last 5 years, have you been treated for or had a recurrence of a diagnosed addictive disorder? Yes No Yes No Yes No EDUCATION HISTORY If you answer “yes” to question 25 below, you must submit the following WITH your application at the time of submission: 1. A statement indicating the details surrounding the instance, including the institution name and address and dates. 2. A statement from the institution regarding the incident and outcome. 25. In the last five years, have you been expelled, suspended from, or had disciplinary action taken against you by an educational institution other than your high school? Yes No AFFIDAVIT OF APPLICATNT: I, ___________________________________________________affirm that I am the person referred to in the foregoing massage therapy licensure application, and that the attached photograph is a true likeness of myself. I understand that it is my duty and responsibility as an applicant for licensure to supplement my application after it has been submitted if and when any material change in circumstances or conditions occur which might affect the Board’s decision concerning my eligibility for examination or licensure. Such supplement is required by Chapter 456.013(1), F.S. Failure to do so may result in disciplinary action by the Board including denial of licensure. I have carefully read the questions in the foregoing application and have answered them completely, without reservation of any kind, and I declare that my answers and all statements made by me herein and in support of this application are true and correct. Should I furnish any false information on or in support of this application, I understand that such action shall constitute cause for denial, suspension, or revocation of any license to practice in the state of Florida in the profession for which I am applying. I have read, understand and agree to comply with the statutes and rules applicable to the practice of my profession in Florida. I understand that in the event I am required to submit to an evaluation by the Professional’s Resource Network, my application documents will be shared with the program and that the program will provide the Board of Massage Therapy and the department with the written results of the evaluation and any recommendations with regard to licensure and my practice of the profession. I understand the application fee is non-refundable. Applicant Signature: ______________________________ Date Signed: ________________________________ TAPE 2x2 PHOTOGRAPH HERE 7 SECTION III: CRIMINAL HISTORY FORM This form must be completed if you answer “yes” to question #20 on the application. Please complete a separate form for EACH offense. You may duplicate this form as necessary. Name: _____________________________________________________________________ Social Security Number: ______________________________________________________ Type of Offense (Circle One): Felony Misdemeanor Location of Occurrence: ________________________________________________________ City State Date of Offense: __________________ Date of Sentencing: ______________________ Offense Type (DUI, Assault, Prostitution, etc.): ___________________________________________ Explanation/details surrounding the offense (attach additional sheets as necessary): Sentencing Information: Please list the details of your sentencing (ie: probation, jail time, fines/costs, programs completed, etc.): Current Disposition: Please list the current disposition of your sentencing: Don’t forget to attach certified documentation from the Clerk of Court pertaining to the arrest/charges, sentencing due to the arrest and proof of successful completion of your sentencing. 8