Fillable (For Out-of-State Applicants Only) Polysomnography Technologist - Out (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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(For Out-of-State Applicants Only) Polysomnography Technologist - Out (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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  • 150 other fields

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BROWSE STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) FORMS

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 6th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Polysomnography Technologist - Out of State
(For Out-of-State Applicants Only)
Date:_______________________________
Anonrefundableapplicationlingfeeof$100.00andalicensefeeof$500.00(foratotalof$600.00)intheformofacheck
ormoneyordermadeouttotheStateofNewJersey,mustbesubmittedwiththisapplication.(Applicantsshouldunderstandthatif
thefeesarepaidwithapersonalcheck,andthecheckisreturnedbythebankduetoinsufcientfunds,thenextstepinthelicensure
orcerticationprocesswillbedelayeduntilthefeesarepaid.)
Iftheapplicationprocessisnotcompletedwithinoneyear,yourapplicationwillbediscardedandyouwillneedtore-applywith
fullpayment.
TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants, without their
consent. However,you arerequiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponseto
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
ofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureof
yourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleased
tothepublic.Oneofyouraddressesmustincludeastreet,city,stateandZIPcode.
InformationthatyouprovideonthisapplicationmaybesubjecttopublicdisclosureasrequiredbytheOpenPublicRecordsAct
(OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Dateofbirth:_______________________
MonthDayYear
Placeofbirth: ______________________
 CityState
Mr.
1. Name
Mrs. ____________________________________________________________ (______________________)
Ms.
Lastname Firstname Middleinitial Maidenname
2. Address
Home:_________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
____________________________________ _________________________________
Telephonenumber(includeareacode) E-mailaddress
 Business:_______________________________________________________________________________________
Nameofcompany Telephonenumber(includeareacode)
________________________________________________________________________________________
Street City State ZIPcode County
 Mailing:________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
Datereceived:
_________________________
Dateofexamination:
_________________________
Attachaclear,full-facepassport-
stylephotograph(2˝x2˝)ofyour
headandshoulders,takenwithin
thepastsixmonths.
A photo is required with each
application.
Donotuse staples to attach the
photo.
Page1of12Revised:3/20/18
3. SocialSecurityNumber
YoumustprovideyourSocialSecuritynumbertotheBoardorCommittee.Failuretodosowillresultindenial/nonrenewalof
licensureorcertication.
*SocialSecurityNumber:  __________ -____________ -___________
*PursuanttoN.J.S.A.54:50-24etseq.oftheNewJerseytaxationlaw,N.J.S.A.2A:17-56.44eoftheNewJerseyChildSupport
EnforcementLaw,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theBoardorCommitteeis
requiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovide
yourSocialSecuritynumberto:
 a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeofreviewing
compliancewithStatetaxlawandupdatingandcorrectingtaxrecords;
b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest;and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship/ImmigrationStatus
FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcerticatestoU.S.citizensorqualiedaliens.
Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot
aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofceofU.S.
CitizenshipandImmigrationServices(USCIS).
 U.S.citizen
 AlienlawfullyadmittedforpermanentresidenceinU.S.
 Otherimmigrationstatus
Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe
USCISat:1-800-375-5283.
5. ChildSupport(You must answer a, b, c and d.)
Pleasecertify,underpenaltyofperjury,thefollowing:
a. Doyoucurrentlyhaveachild-supportobligation? Yes No
(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No
(2)If“Yes,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No
b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No
c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No
d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No
InaccordancewithN.J.S.A.2A:17-56.44d,ananswerof“Yes”toanyofthequestionsa(1)throughdwillresultinadenialof
licensureorcertication.Furthermore,anyfalsecerticationoftheabovemaysubjectyoutoapenalty,including,butnotlimited
to,immediaterevocationorsuspensionoflicensureorcertication.
 ___________________________________ ___________________________________ ________________________

Applicant’sname(pleaseprint) Applicant’ssignature Date
Page2of12
click to sign
signature
click to edit
6. IllegalUseofControlledDangerousSubstances
Thequestionbelowpertainstotheillegaluseofcontrolleddangeroussubstances.Pleasereadthedenitionscarefully.Yourresponses
willbetreatedcondentiallyandretainedseparately.Pleasebeawarethatyouhavetherighttoelectnottoanswerthisquestion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certication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ontheFifthAmendment,providedthattheAttorneyGeneralrstgrantsyouimmunity
affordedbystatutorylaw,(N.J.S.A.45:1-20).
“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
365days,whicheverislonger.
“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. Areyoucurrentlyengagedintheillegaluseofcontrolleddangeroussubstances?(Asstatedabove,“currently”isdenedas
“recentlyenough…[to]haveanongoingimpact…”or“withintheprevious365days,”whicheverislonger.)
 Yes No
Ifyouanswered“Yes,”areyoucurrentlyparticipatinginasupervisedrehabilitationprogramorprofessionalassistanceprogram
thatmonitorsyouinordertoassurethatyouarenotengagingintheillegaluseofcontrolleddangeroussubstances?
 Yes No
_____________________________________________________ ___________________________________
Applicant’ssignature Date
Page3of12
click to sign
signature
click to edit
7. Haveyoueverchangedyourname? Yes No
If“Yes,”pleasesubmitwiththisapplicationacopyofthemarriagecerticate,divorcedecreeorcourtorder.
8. Doyoucurrentlyhold,orhaveyoueverheld,aprofessionallicenseorcerticateofanykindinNewJersey,anyotherstate,the
DistrictofColumbiaorinanyotherjurisdiction Yes No
If“Yes,”foreachlicenseorcerticateheld,providethedate(s)heldandthenumber(s).Ifthelicenseorcerticatewasissuedunder
adifferentname,pleaseprovidethatname.____________________________________________________________________
LastnameFirstname Middleinitial
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
9. HaveyoueverbeendisciplinedordeniedaprofessionallicenseorcerticateofanykindinNewJersey,anyotherstate,theDistrict
ofColumbiaorinanyotherjurisdiction?   Yes No
10. Haveyoueverhadaprofessionallicenseorcerticateofanytypesuspended,revokedorsurrenderedinNewJersey,anyotherstate,
theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
11. Has any action (including the assessment of fines or other penalties) ever been taken against your professional practice
byanyagencyorcerticationboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? 
  Yes No
12. Haveyoueverbeennamedasadefendantinanylitigationrelatedtothepracticeofpolysomnographyorotherprofessionalpractice
inNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?   Yes No
13.Have you ever been summoned; arrested; taken intocustody; indicted; tried; chargedwith; admitted into pre-trial intervention
(P.T.I.);orpledguiltytoanyviolationoflaw,ordinance,felony,misdemeanorordisorderlypersonsoffense,inNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?(Parkingorspeedingviolationsneednotbedisclosed,butmotorvehicle
violationssuchasdrivingwhileimpairedorintoxicatedmustbe.) Yes No
14. Haveyoueverbeenconvictedofanycrimeoroffenseunderanycircumstances?Thisincludes,butisnotlimitedto,apleaofguilty,
nonvult,nolocontendere,nocontest,orandingofguiltbyajudgeorjury.  Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide acomplete
explanation.(Attachadditionalsheetsofpapertothisapplication.)
15. AreyouawareofanyinvestigationpendingagainstaprofessionallicenseorcerticateissuedtoyoubyaprofessionalboardinNew
Jersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
16. ArethereanycriminalchargesnowpendingagainstyouinNewJersey,anyotherstate,theDistrictofColumbiaorinanyother
jurisdiction?  Yes No
17. Haveyoueverbeensanctionedbyorisanyactionpendingbeforeanyemployer,association,society,orotherprofessionalgroup
relatedtothepracticeofpolysomnographyorotherprofessionalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaor
inanyotherjurisdiction?  Yes No
Iftheanswertoanyoftheabovequestions,numbers9through17,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
Page4of12
Employment History
1. Pleasedocumentyourworkexperienceoverthelastveyearsregardlessofemploymentstatus(paid,unpaid,full-time,perdiem,
contractororother).Beginwithyourcurrentormostrecentexperienceanddonotomitanyworkexperience.Attachaseparatesheet
withexplanationifthereareanygapsbetweenwork.
(a) Employer:___________________________________________________________________________________________
Address:____________________________________________________________________________________________
Streetaddress City State ZIPcode
Telephonenumber:__________________________________
(includeareacode)
Titleofyourposition:__________________________________________________ Hoursperweek:__________________
Yourmajorresponsibilities(useadditionalsheetsofpaperifnecessary):__________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From____________________________________________ to ________________________________________________
Month Year Month Year
Immediatesupervisor’snameandtitle:____________________________________________________________________
(b) Employer:___________________________________________________________________________________________
Address:____________________________________________________________________________________________
Streetaddress City State ZIPcode
Telephonenumber:__________________________________
(includeareacode)
Titleofyourposition:__________________________________________________ Hoursperweek:__________________ 
Yourmajorresponsibilities(useadditionalsheetsofpaperifnecessary):__________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From____________________________________________ to ________________________________________________
Month Year Month Year
Immediatesupervisor’snameandtitle:____________________________________________________________________
(c) Employer:___________________________________________________________________________________________
Address:____________________________________________________________________________________________
Streetaddress City State ZIPcode
Telephonenumber:__________________________________
(includeareacode)
Titleofyourposition:__________________________________________________ Hoursperweek:__________________
Yourmajorresponsibilities(useadditionalsheetsofpaperifnecessary):__________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From____________________________________________ to ________________________________________________
Month Year Month Year
Immediatesupervisor’snameandtitle:____________________________________________________________________
Page5of12
1.) License Verication
YoumustprovidedocumentationtotheBoardthatyourlicenseinalloftheotherstatesinwhichyouarelicensedisvalid,currentandin
goodstanding.Goodstandingmeansthat:
a) Noactionhasbeentakenagainstyourlicensebyanylicensingboard;
b) Noactionaffectingyourprivilegestopracticeyourprofessionasatechnologisthasbeentakenbyanyout-of-stateinstitution,
organizationoremployer;
c) Nodisciplinaryproceedingispendingthatcouldaffectyourprivilegestoactasatechnologist;
d) Allnesleviedbyanyout-of-stateboardhavebeenpaid.
2.) Basic Life Support
Youmustprovideproofthatyouholdacurrent(notexpired)certicationinBasicLifeSupportfortheHealthProviderfromthe
AmericanHeartAssociationorCardioPulmonaryResuscitation/AutomatedExternalDebrillator(CPR/AED)fortheProfessional
RescuerfromtheAmericanRedCross.
Pleaseprovideacopy(frontandback)ofyourcertication.
3.) Technologist Endorsement Exam
ArrangefortheBoardofRegisteredPolysomnographicTechnologiststosubmitevidencethatyouhavesuccessfullycompletedthe
certicationexaminationandhavetheRPSGTcredentialsent directlytotheStateBoardofPolysomnography.
4.) Verication of RPSGT Credentials
By E-mail (preferred)
YoucanhavetheBRPTe-mailtheStateBoardofPolysomnographyvericationofyourRPSGTcredential.Pleasee-mailtheBPRT
atinfo@brpt.org.
PleasebesuretotypeRPSGT vericationinthesubjectlineofyoure-mail.
Includethefollowinginformationinthebodyofyoure-mail:
Your Full Name
Your RPGST Credential Number
I am requesting that the BRPT please forward verification of my RPSGT credential to the State Board of
Polysomnography at njpolysomnography@dca.lps.state.nj.us
By U.S. Mail
You can write to BRPTand have your ofcial Board of Registered Polysomnographic Technologists verication sent directly
totheBoardofceat:StateBoardofPolysomnography,P.O.Box45051,Newark,NewJersey07101.

Page6of12
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
Stateof:__________________________________________________
Countyof:________________________________________________
I, ________________________________________________ , in making this application to the State Board of Polysomnography,
for licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey and the Rules of the State
Board of Polysomnography, swear (or affirm) that I am the applicant and that all information provided in connection
withthisapplicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomake
fulldisclosuresmaybedeemedsufcienttodenylicensureorcerticationortowithholdrenewaloforsuspendorrevokealicenseor
certicateissuedbytheBoard.
Ifurtherswear(orafrm)thatIhavereadN.J.S.A.45:14G-1etseq.,togetherwiththeRulesandRegulationsoftheStateBoardof
Polysomnography,N.J.A.C.13:44L-1.1through6.1,andfullyunderstandthatinreceivinglicensureorcerticationfromtheBoard,I
bindmyselftobegovernedbythem.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for
thepurposeofverifyingmyqualicationsforlicensureorcertication.Ifurtherauthorizeallinstitutions,employers,agenciesandall
governmentalagenciesandinstrumentalities(local,state,federalorforeign)toreleaseanyinformation,lesorrecordsrequestedby
theBoard.
__________________________________________________
Signatureofapplicant
Swornandsubscribedtobeforemethis__________________
dayof ____________________________ ,______________
MonthYear
__________________________________________________
NameofNotaryPublic(pleaseprint)
__________________________________________________
SignatureofNotaryPublic
Afx Seal Here
} ss.
Page7of12
click to sign
signature
click to edit
click to sign
signature
click to edit
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
CertifiCAtion And AuthorizAtion form
f
or A CriminAl history BACkground CheCk
Directions:Answerallofthequestionsonthisform.
1. Name _________________________________________________________ ( ________________________)
LastFirstMiddle MaidenName
2. Address___________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode
3. Dateofbirth____/____/____ Sex: Male Female
MonthDayYear 
4. SocialSecuritynumber_________/_____ / ________

5. HaveyoucompletedthengerprintingprocessforanyBoard or Committee of the New Jersey Division of Consumer
AffairssinceNovember2003?
Yes No
If“No,”youwillreceiveaseparatemailingfromtheBoardorCommitteeregardingthecriminalhistoryrecordbackground
checkprocess.Nopaymentisnecessaryasofnow.
If“Yes,”pleaseprovidethefollowinginformationandfollowtheinstructionsoutlinedbelow:
_______________________________________________ _______________________________________________
BoardorcommitteerequiringthengerprintingMonthandyearyouwerengerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certicationbyanyotherBoard or Committee of the New Jersey Division of Consumer Affairs(abackgroundcheck
conductedfortheDepartmentofEducation,anotherstateagencyoranotherstatedoesnotapply)youwillnotberequiredto
bengerprintedasecondtime.However,theDivisionmustperformacriminalhistorybackgroundcheckeachtimeyouapply
forlicensureorcertication.The fee for this service is $18.75.Paymentshouldbemadeintheformofacheckormoney
orderpayabletotheStateofNewJerseyandshouldaccompanyyourapplicationpacket.
6. Haveyoueverbeenarrestedand/orconvictedofacrimeoroffense?(Minortrafcoffensessuchasaparkingorspeeding
violationsneednotbelisted.)
Yes No
Every such conviction on record must be disclosed. Atruecopyofeverypolicereport,judgmentofconviction,sentencing
orderandterminationofprobationorder,ifapplicable,must besubmittedwiththisform.Anydocuments(includingemployer
orsupervisorlettersofreference,ifapplicable)whichpresentclearandconvincingevidenceofrehabilitationmust besubmitted
withthisform.Failure to follow these instructions may result in the denial of an initial application.
Note: Copiesofjudgments,sentencingandterminationofprobationordersmaybeobtainedfromtheclerkofthecounty
wherethoseorders,disposingoftheconviction,wereissuedandled.
Your continuing responsibility to disclose convictions of crimes or offenses:Youmust notifytheBoardorCommittee
withinve(5)businessdaysifyouareconvictedofanycrimesoroffensesafterthisformhasbeencompleted.
Mr.
Mrs.
Ms.
BoardorCommittee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
DualLicense
LicenseType1
________________________
Applicant’sNumber
________________________
LicenseType2
________________________
Applicant’sNumber
________________________
Page8of12
CertifiCAtion
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
applicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefull
disclosuresmaybedeemedsufcienttodenycerticationorlicensureortowithholdrenewaloforsuspendorrevokeacerticate
orlicenseissuedbytheBoardorCommittee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualications for certication or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requestedbytheBoardorCommittee.
Icertifythattheforegoingstatementsmadebymearetrue.Iamawarethatifanyoftheforegoingstatementsmadebymeare
willfullyfalse,Iamsubjecttopunishment.
__________________________________________________________ _________________________________

SignatureofapplicantDate
Rev.1/2/19
Page9of12
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signature
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 6th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Verication of Hospital/Medical Employment, Privileges or Appointment
Applicant’sName:_____________________________________________________________________________________________
Name
o
f
H
ospital/Facility:
_
__________________________________________________________________________________________
Hospital/Facility
A
ddress:___________________________________________________________________________________________
Hospital/Facility
T
elephone
N
umber:__________________________________________________________________________________
1. What
position
did
this
health
practitioner
hold
at
your
facility?
______________________________________________________
2. Whatwerethishealthpractitioner’sdatesofemploymentatyourfacility?_____________________________________________
3. Wasthishealthpractitioneronprobation,suspended,sanctionedorinanyway
sanctioned/disciplinedwhileatyourfacility? 
Yes No
4. Wasthishealthpractitionergrantedaleaveofabsencewhileemployedat
yourfacility? 
Yes No
5. Wereanyrestrictionsplacedonthishealthpractitioner’sactivitieswhichwere
notplacedonallotheremployeesholdingsimilarpositions? 
Yes No
6. Wereanyrestrictionsplacedonthishealthpractitioner’sprivileges?

Yes No
7. Wereanyformalpatientorstaffcomplaintsledagainstthishealthpractitioner?
Yes No
8.
 Wereanyincidentreportsledinvolvingtheprofessionalconductorbehaviorof
thishealthpractitioner? 
Yes No
9. Wasthishealthpractitionereversubjecttononroutinemonitoringwhileinyourfacility?
Yes No
10.Wasthishealthpractitionerinvoluntarilyremovedfromacallscheduleforcause?
Yes No
11.Wasthishealthpractitionereversubjecttononroutinequalityassessmentreview?

Yes No
12. Wasthishealthpractitionerthesubjectofanegativereviewbyaqualityassurance
ordepartmentalcommittee?  
Yes No
13. Wasthishealthpractitionerthesubjectofaninvestigationbyyourfacilityorany
committeeordepartmentofyourfacility? 
Yes No
14. Wereanymalpracticeactionslednamingthishealthpractitionerasadefendantthat
involvedhisorherperiodofemploymentatyourfacility? 
Yes No
If
you
have
answered
“Y
es”
to
any
of
the
questions
above,
please
explain:
______________________________________________
_________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Pleaseseeotherside.
Page10of12
15. Didthishealthpractitionerleaveyourfacilityingoodstanding?

Yes No
16. Wouldyouconsiderre-hiringthishealthpractitionerforapositionatyourfacility?

Yes No
17. Wouldyourecommendthishealthpractitionerforprivilegesatyourfacility?

Yes No
If
you
have
answered
“No” to
questions
15,
16
or
17,
please
explain:
________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
18. Please
s
upply
a
ny
a
dditional
c
omments
o
r
i
nformation
t
hat
t
he
B
oard
s
hould
c
onsider
p
rior
t
o
d
etermining
t
his
a
pplicant’s
eligibilityforlicensure.
_________________________________________________________________________________________________________
Print
t
he
n
ame
a
nd
t
itle
o
f
c
ertifying
o
fcial:_____________________________________________________________________
Signature
o
f
c
ertifying
o
fficial:______________________________________________________________________
Dateformwascompleted:_________________________________________________________
NOTE:
P
lease attach letterhead or business card from the facility where the applicant worked or supply some form of identication
for
the individual supplying information.
PLEASE RETURN DIRECTLY TO:
State Board of Polysomnography
124 Halsey Street, 6th Floor,
P.O. Box 45051
Newark, New Jersey 07101
SEAL OF HOSPITAL
(IfApplicable)
Page11of12
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 6th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
License/Certication
Verication Request
Directions:Completeonlythetopportionofthislicense/certicationformandforwardittothelicense/certication
agencyinthestateinwhichyouarelicensed/certied.TheagencyshouldcompletetheformandreturnittotheState
BoardofPolysomnography.Note:Beadvised thatthe agency completing the form may chargea fee for license/
certicationverication.Pleasecalltheagencytocheckonfeesforlicense/certicationvericationpriortosubmitting
thisform.
Name:_______________________________________________________________________________________
FirstName MiddleName LastName MaidenName,ifapplicable
Nameonoriginallicense/certication:__________________________ Telephonenumber:___________________
(includeareacode)
Currentaddress: _______________________________________________________________________________
Street City State ZIPcode
License/Certicationnumber:_______________________________ Yearissued: _______________
Thissectionistobecompletedbythestatelicensing/certicationagency.
1. License/Certicationnumber:__________________________Dateissued:____________________________
2. Whenwasthelicense/certicatelastrenewed?____________________________________________________
3. Isthelicense/certicateingoodstanding? Yes No
4. Hasthislicense/certication ever been revoked,suspendedorvoluntarily surrendered or has anyactionbeen
takenbyyouragencyagainstthislicensee? Yes No

If“Yes,”pleaseprovideadescriptionofthereasonand/orcharge(s)andanyaction(s)takenandprovideacopy
ofanycomplaint,orderorrelevantdocument.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Icertifythatthestatementscontainedhereinaretruebaseduponofcialrecords
thatIreviewed.

Print Name _____________________________________________________________________
Signature _______________________________________________________________________
Title ___________________________________________________________________________
State ________________________________Date______________________________________
Ofcial
Seal
Page12of12
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(For Out-of-State Applicants Only) Polysomnography Technologist - Out (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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