Allied Health Clinical Program Application

Semester and Year (i.e., Fall 2019)

Have you even been enrolled in a Health Science program at another school?
Health care license ever revoked, suspended, or restricted?

The following questions must be answered honestly and truthfully:

Have you had, or do you now have pending, any disciplinary action against you by licensing or certifying board in any state?
Have you ever been arrested, charged with, convicted of, plead guilty or no contest to, or adjusted a juvenile delinquent, for any criminal offense in any state? (Even though an arrest, conviction or plea has been pardoned, expunged, dismissed or your civil rights have been restored, you must answer “yes”. You may answer “no” if the juvenile offense has been expunged.
Within the past five (5) years, have you habitually used or been diagnosed as addicted to drugs or alcohol?
Do you have any physical or mental impairment which may affect your ability to practice safely as a health care provider?
***Failure to disclose or to incorrectly answer the previous questions constitutes falsification of documents and may result in delay or denial of certification as a health care provider.

Instructions:

If you answered “yes” to any of the previous questions on this form, the following appropriate documentation must be submitted directly to the Allied Health Department Chair by the student for review and action sixty (60) days prior to anticipated enrollment in a Health Science course.  Any subsequent reportable incident(s) must be immediately submitted to the Allied Health Department Chair.  A copy will be retained in the Department of Allied Health records.

  1. A written detailed explanation of any item with a “yes”.  Provide circumstances of action, criminal act, arrest, addiction, or impairment; and
  2. Certified copies of any of the following documents that apply:
    • Disciplinary charge, action and final clearance by the licensing/certifying board.
    • Arrest, charge, bill of information or indictment
    • Judgement and sentencing
    • Completion of the court ordered probation and release from probation, and
    • Pardon, if received.
  3. Documentation of the medical evaluation, diagnosis and treatment if you answered “yes” to question 4 regarding physical or mental impairment.

Reporting of subsequent arrests, convictions or impairment:

If a student is admitted to the clinical sequence of the program, any subsequent action, arrest, criminal charge or conviction or impairment shall be immediately reported to the Department of Allied Health.

I certify that the information on this form is true and accurate.

Type your full name in the box to serve as your signature.