| (a) Original documents include, but are not limited
to, those listed in subsections (b) and (c) of this section.
(b) Documentation required of all applicants for licensure.
(1) Birth Certificate/Proof of Age. Each applicant
for licensure must provide a copy of a birth certificate and translation
if necessary to prove that the applicant is at least 21 years of age.
In instances where a birth certificate is not available the applicant
must provide copies of a passport or other suitable alternate documentation.
(2) Name change. Any applicant who submits documentation
showing a name other than the name under which the applicant has applied
must present copies of marriage licenses, divorce decrees, or court
orders stating the name change. In cases where the applicant's name
has been changed by naturalization, the applicant should send the
original naturalization certificate by certified mail to the board
office for inspection.
(3) Examination verification. Each applicant for licensure
must have the appropriate testing service that administered the required
perfusionist competency examination, described in §188.4 of this
chapter (relating to Qualifications for Licensure), submit verification
of the applicant's passage of the examination directly to the board
or verification of current certification by the ABCP.
(4) Certificate from Educational Program or other State
License. All applicants must submit:
(A) a certificate of successful completion of an educational
program as described in §188.4 of this chapter, unless the applicant
qualifies for the special eligibility provision regarding education
under §188.4 of this chapter;
(B) If an applicant is or has been licensed, certified,
or registered in another state, territory, or jurisdiction, the applicant
must submit information required by the board concerning that license,
certificate or registration on official board forms.
(5) Transcripts. Each applicant must have his or her
educational program(s) submit a transcript of courses taken and grades
obtained to demonstrate compliance with curriculum requirements under §188.4
of this chapter.
(6) Evaluations.
(A) All applicants must provide evaluations, on forms
provided by the board, of their professional affiliations for the
past three years or since graduation from an educational program,
in compliance with §188.4 of this chapter, whichever is the shorter
period.
(B) The evaluations must come from at least three supervisors
or instructors who are either licensed perfusionists or licensed physicians
and have each supervised the applicant's work experience.
(C) An exception to subparagraph (B) of this paragraph
may be made for those applicants who provide adequate documentation
that they have not been supervised by at least three licensed physicians
or licensed perfusionists for the three years preceding the board's
receipt of application or since graduation, whichever is the shorter
period.
(7) License verifications. Each applicant for licensure
who is licensed, registered, or certified in another state must have
that state submit, directly to the board, proof that the applicant's
license, registration, or certification is current and in full force
and that the license, registration, or certification has not been
restricted, suspended, revoked or otherwise subject to disciplinary
action. The other state shall also include a description of any sanctions
imposed by or disciplinary matters pending in the state.
(c) Applicants may be required to submit other documentation,
which may include the following:
(1) Translations. Any document that is in a language
other than the English language will need to have a certified translation
prepared and a copy of the translation submitted with the translated
document.
(A) An official translation from the school or appropriate
agency attached to the foreign language transcript or other document
is acceptable.
(B) If a foreign document is received without a translation,
the board will send the applicant a copy of the document to be translated
and returned to the board.
(C) Documents must be translated by a translation agency
who is a member of the American Translation Association or a United
States college or university official.
(D) The translation must be on the translator's letterhead,
and the translator must verify that it is a "true word for word translation"
to the best of his/her knowledge, and that he/she is fluent in the
language translated, and is qualified to translate the document.
(E) The translation must be signed in the presence
of a notary public and then notarized. The translator's name must
be printed below his/her signature. The notary public must use the
phrase: "Subscribed and Sworn this _______ day of ________, 20___."
The notary must then sign and date the translation, and affix his/her
notary seal to the document.
(2) Arrest records. If an applicant has ever been arrested,
the applicant must request that the arresting authority submit to
the board copies of the arrest and arrest disposition.
(3) Inpatient treatment for alcohol/substance disorder
or mental illness. An inpatient facility shall include a hospital,
ambulatory surgical center, nursing home, and rehabilitation facility.
Each applicant that has been admitted to an inpatient facility within
the last five years for treatment of alcohol/substance disorder or
mental illness (recurrent or severe major depressive disorder, bipolar
disorder, schizophrenia, schizoaffective disorder, or any severe personality
disorder), or a physical illness that impairs or has impaired the
applicant's ability to practice perfusion, shall submit documentation
must submit the following:
(A) applicant's statement explaining the circumstances
of the inpatient treatment/hospitalization;
(B) all records, submitted directly from the inpatient
facility;
(C) a statement from the applicant's treating physician/psychotherapist
as to diagnosis, prognosis, medications prescribed, and follow-up
treatment recommended; and
(D) a copy of any contracts signed with any licensing
authority, professional society or impaired practitioner committee.
(4) Outpatient treatment for alcohol/substance disorder
or mental illness. Each applicant that has been treated on an outpatient
basis within the past five years for alcohol/substance disorder or
mental illness (recurrent or severe major depressive disorder, bipolar
disorder, schizophrenia, schizoaffective disorder, or any severe personality
disorder), or a physical illness that impairs or has impaired the
applicant's ability to practice perfusion, shall submit documentation
to include, but not limited to the following:
(A) applicant's statement explaining the circumstances
of the outpatient treatment;
(B) a statement from the applicant's treating physician/psychotherapist
as to diagnosis, prognosis, medications prescribed, and follow-up
treatment recommended; and
(C) a copy of any contracts signed with any licensing
authority, professional society or impaired practitioners committee.
(5) Malpractice. If an applicant has ever been named
in a malpractice claim filed with any liability carrier or if an applicant
has ever been named in a malpractice suit, the applicant must:
(A) have each liability carrier complete a form furnished
by this board regarding each claim filed against the applicant's insurance;
(B) for each claim that becomes a malpractice suit,
have the attorney representing the applicant in each suit submit a
letter to the board explaining the allegation, relevant dates of the
allegation, and current status of the suit. If the suit has been closed,
the attorney must state the disposition of the suit and, if any money
was paid, the amount of the settlement. If such letter is not available,
the applicant will be required to furnish a notarized affidavit explaining
why this letter cannot be provided; and
(C) provide a statement composed by the applicant,
explaining the circumstances pertaining to patient care in defense
of the allegations.
(6) Additional documentation. Additional documentation
may be required as is deemed necessary to facilitate the investigation
of any application for licensure.
(d) The board may, in unusual circumstances, allow
substitute documents where proof of exhaustive efforts on the applicant's
part to secure the required documents is presented. These exceptions
are reviewed by the board's executive director on a case-by-case basis.
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