Fillable Printable Form 50819

Form 50819

APPLICATION FOR STUDENT PERMIT

TO PRACTICE RESPIRATORY CARE

State Form 50819 (R5 / 9-17)

Approved by State Board of Accounts, 2017

APPLICATION FEE

DATE FEE PAID (month, day, year)

RECEIPT NUMBER

STUDENT PERMIT NUMBER

STUDENT PERMIT ISSUE DATE (month, day, year)

STUDENT PERMIT EXPIRATION DATE (month, day, year)

APPLICANT

Attach one (1) passport

type quality photograph of

yourself taken within the

last eight (8) weeks.

APPLICANT INFORMATION

SCHOOL OR PROGRAM OF RESPIRATORY CARE CURRENTLY ENROLLED

NAME OF SCHOOL LOCATION OF SCHOOL

DATE ENTERED

(month, day, year)

DATE OF EXPECTED GRADUATION

(month, day, year)

OTHER SCHOOLS OR PROGRAMS ATTENDED

NAME OF SCHOOL LOCATION OF SCHOOL

DATES ATTENDED

(month, day, year)

DEGREE GRANTED

(month, day, year)

Page 1 of 6

RESPIRATORY CARE COMMITTEE

PROFESSIONAL LICENSING AGENCY

402 West Washington Street, Room W072

Indianapolis, Indiana 46204

Telephone: (317) 234-2054

E-mail: [email protected]

www.pla.IN.gov

DO NOT WRITE ABOVE THIS LINE

Do you hold or have you ever held a student permit?

BASIS OF APPLICATION (please check one)

New applicant - applying for the first time for a student permit

Change of hospital or facility of employment

Additional hospital or facility employment - adding an additional hospital or facility of employment

Change of respiratory care procedures - adding additional procedures the student permit holder may provide

Transfer of school

Change of graduation date

Are you the spouse of a member of the military who is assigned to a duty station in Indiana? (Optional)

Yes No

INSTRUCTIONS: 1. The fee for this application is $25.00, payable to the Indiana Professional Licensing Agency, in accordance with 844 IAC 11-2-1.1.

2. Completed application and fees should be mailed to the address listed in the upper right hand corner of this form.

3. All fees are non-refundable and non-transferable.

4. Please refer to the instructions on our website, www.pla.in.gov, for the licensing requirements.

* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.

** This information is being requested for workforce statistical purposes only; disclosure is voluntary.

Name of applicant (last, first, middle)

Date of birth (month, day, year)

Address of applicant (number and street or rural route)

Social Security number

Telephone number (daytime)

( )

City, state, and ZIP code

E-mail address

Place of birth (city and state or country)

Gender **

Male Female

Pursuant to IC 12-32-1-5 and IC 12-32-1-6, I swear under the penalty of perjury that: (Please select one of the following.)

I am a United States Citizen. I am a qualified alien (as defined under 8 U.S.C. § 1641).

Race **Ethnicity **

If yes, please list student permit number(s).

Yes No

Reset Form

Yes No

LIST ALL PLACES YOU HAVE LIVED SINCE ENROLLING IN YOUR SCHOOL OR PROGRAM

GENERAL LOCATION DATES (month, day, year)

LIST ALL PLACES WHERE YOU HAVE BEEN EMPLOYED TO PRACTICE RESPIRATORY CARE PRIOR TO APPLYING FOR A STUDENT PERMIT

EMPLOYER ADDRESS (number and street, city, state, and ZIP code)

DATES OF EMPLOYMENT

(month, day, year)

Page 2 of 6

2. Has disciplinary action ever been taken regarding any license, certificate, registration or permit you hold or have held?

3. Have you ever been denied a license, certificate, registration or permit to practice respiratory care or any regulated health

occupation in any state (including Indiana) or country?

4. Except for minor violations of traffic laws resulting in fines, and arrests or convictions that have been expunged by a court,

(1) have you ever been arrested;

(2) have you ever entered into a prosecutorial diversion or deferment agreement regarding any offense, misdemeanor, or felony

in any state;

(3) have you ever been convicted of any offense, misdemeanor, or felony in any state;

(4) have you ever pled guilty to any offense, misdemeanor, or felony in any state; or

(5) have you ever pled nolo contendre to any offense, misdemeanor, or felony in any state?

5. Do you have any condition or impairment (including a history of alcohol or substance abuse) that currently interferes, or if left

untreated may interfere, with your ability to practice in a competent and professional manner?

6. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or

privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations?

7. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health

care facility in which you have trained, held staff membership or privileges or acted as a consultant?

APPLICATION AFFIRMATION

I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.

Date signed (month, day, year)Signature of applicant

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing

Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of their authorized

representatives in connection with processing my application for a student permit to practice repertory care.

I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such

inspection or furnishing of any such information.

A photostatic copy of this authorization has the same force and effect as the original.

AFFIRMATION

I hereby swear or affirm, that I have read the above statements and agree to same.

Date signed (month, day, year)

Signature of applicant

1. Have you ever previously filed an application in the State of Indiana?

AFFIRMATION

Yes No

If your answer is “Yes” to any of the following, explain fully in a sworn affidavit, including all related details, and provide copies of all relevant arrest or

court documents. Describe the event including the location, date and disposition. Falsification of any of the following is grounds for permanent revocation

of the license or permit issued pursuant to this application.

Yes No

OTHER SCHOOLS OR PROGRAMS ATTENDED (continued)

Do you hold or have you ever held, a license, certificate, registration or permit to practice any regulated health occupation?

If yes, please explain.

Yes No

Page 3 of 6

I understand the following as a holder of a student permit:

I shall meet in person at least one (1) time each working day with my supervising practitioner or a designated respiratory care practitioner to review the

permit holder’s clinical activities. The supervising practitioner or a designated respiratory care practitioner shall review and countersign the entries that

the permit holder makes in the patient’s medical record not more than seven (7) calendar days after the permit holder makes the entries.

I may only perform procedures that I have successfully completed and documented in the respiratory care program, AND that the Committee has approved

and are on file at the Professional Licensing Agency.

The procedures permitted may be performed ONLY on adult patients who are not critical care patients and under the proximate supervision of a licensed

respiratory care practitioner. This means that the student permit holder may not perform blood gas sampling and analysis, work in ICU, ER, or Pediatrics.

The student permit holder, working under the student permit, MAY NOT perform blood gas sampling and analysis, work in ICU, ER, and Pediatrics after

graduation. The new graduate may work in the above-mentioned areas ONLY after applying for AND receiving a temporary permit, as described above.

A student permit expires on the earliest of the following:

The date a student permit holder is issued a respiratory care license or temporary permit.

The date the Committee disapproves the student permit holder’s application for a license.

The date the student permit holder ceases to be a student in good standing in a respiratory care program.

Sixty (60) days after the date that the student permit holder graduates from a respiratory care program.

The date that the student permit holder is notified that he / she failed the licensure examination.

Two (2) years after the date of issuance.

Signature of applicant Date signed (month, day, year)

PART II.

APPLICATION FOR A STUDENT PERMIT TO PRACTICE RESPIRATORY CARE

HOSPITAL OR FACILITY OF EMPLOYMENT

Part of State Form 50819 (R5 / 9-17)

(This form is to be completed by the hospital or facility where the applicant will be employed.)

NAME OF STUDENT

Name of student Social Security number *

NAME OF LICENSED RESPIRATORY CARE PRACTITIONER SUPERVISOR DESIGNEE

Name of RCP supervisor designee

Respiratory care license number

Telephone number

Expiration date (month, day, year)

E-mail address

HOSPITAL OR FACILITY OF EMPLOYMENT

Name of hospital or facility

Address (number and street or rural route)

City State ZIP code

APPLICATION AFFIRMATION

I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.

Signature of licensed respiratory care practitioner Date signed (month, day, year)

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SUPERVISION OF STUDENT PERMIT HOLDER

ACCORDING TO IC 25-34.5-2-14(f) & (g):

(f) A holder of a student permit shall meet in person at least one (1) time each working day with the permit holder’s supervising

practitioner or a designated respiratory care practitioner to review the permit holder’s clinical activities. The supervising practitioner

or a designated respiratory care practitioner shall review and countersign the entries that the permit holder makes in a patient’s

medical record not more than seven (7) calendar days after the permit holder makes the entries.

(g) A supervising practitioner may not supervise at one (1) time more than three (3) holders of student permits issued under this section.

IF THE STUDENT PERMIT HOLDER LEAVES YOUR EMPLOYMENT YOU MUST NOTIFY THE RESPIRATORY CARE COMMITTEE.

( )

Please return this application to the following address:

Professional Licensing Agency

402 West Washington Street, Room W072

Indianapolis, Indiana 46204

Telephone: (317) 234-2054

E-mail: [email protected]

PART III.

APPLICATION FOR A STUDENT PERMIT TO PRACTICE RESPIRATORY

SCHOOL OR PROGRAM OF RESPIRATORY CARE

PROCEDURES COMPLETED BY THE STUDENT PERMIT HOLDER

Part of State Form 50819 (R5 / 9-17)

(To be completed by the Program Director and Director of Clinical Education of the Respiratory Care School or Program.)

APPLICANT INFORMATION

Name of student Social Security number *

SCHOOL OR PROGRAM OF RESPIRATORY CARE

Name of school or program

Date of admission (month, day, year)

Address (number and street or rural route)

City

Name of program director

Telephone number

Name of program director of clinical education

Telephone number

E-mail address

State ZIP code

Date of expected graduation (month, day, year)

AFFIRMATION

I hereby swear or affirm that the applicant is a student in good standing in a program or school of respiratory care which is approved by the Indiana

Respiratory Care Committee and the applicant has successfully completed the list of procedures which is attached to this application.

Signature of program director

Signature of program director of clinical education

Date signed (month, day, year)

The program director or director of clinical education must notify the Indiana Respiratory Care Committee if the student ceases to be in

good standing in the respiratory care program. Failure to do so may be grounds for disciplinary action.

Page 5 of 6

( )

Please return this application to the following address:

Professional Licensing Agency

402 West Washington Street, Room W072

Indianapolis, Indiana 46204

Telephone: (317) 234-2054

E-mail: [email protected]

RESPIRATORY CARE PROCEDURES

Please check-off the procedures which have been a part of a course that the applicant has successfully completed in the respiratory care program and

completion has been documented in both lecture and lab, and also in clinical.

Please note that the procedures permitted may be performed only:

(1) on adult patients who are not critical care patients; and

(2) under the proximate supervision of a licensed respiratory care practitioner.

PROCEDURES CHECK-OFF

Completed

1. Aerosol Medication Delivery

2. Airway Clearance Techniques

3. Capnography

4. Chest Physiotherapy

5. Completion of Basic Respiratory Pharmacology

6. Cylinders

7. Directed Cough Technique

8. EKG

9. Endotracheal Suctioning

10. Flow Meters

11. Gas Regulators

12. Humidity and Aerosol Therapy

13. Incentive Spirometry

14. Intermittent Volume Expansion

15. Liquid Systems

16. Manual Ventilation

17. Medical Records

18. Metered Dose Inhaler

19. Minute Ventilation

20. Nasotracheal Suctioning

21. Oxygen Analysis

22. Oxygen Therapy

23. Oxygen / Medical Gas Administration

24. Patient Interview and History

25. Peak Flow

26. Pharyngeal Airway Insertion

27. Physical Assessment of Chest

28. Spirometry Screening

29. Sputum Inductions

30. Tidal Volume

31. Tracheostomy Care

32. Transutaneous Monitors

33. Standard Precautions

34. Vital Capacity

35. Vital Signs

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