Fillable Respiratory Care Practitioner - Application For Licensure Packet (California)

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Respiratory Care Practitioner - Application For Licensure Packet (California)

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RESPIRATORY CARE PRACTITIONER
APPLICATION FOR LICENSURE PACKET
INFORMATION
APPLICATION FOR LICENSURE OVERVIEW
Applicants can submit their completed Application for Licensure packet to the Respiratory Care
Board of California (Board) either once they have met the education requirements (completion of
an approved respiratory care program AND the minimum of an Associate’s Degree) or up to 90
days prior to meeting the education requirements. New graduates are encouraged to submit their
application as soon as possible (but not earlier than the 90-day time period) to allow ample time to
process the application. Applicants have one year from the time they file their initial application to
complete the application process.
The application fee is $300. If you are applying from out of California and submitting fingerprint
cards in lieu of live scan (see below for details), you must submit an additional $49. The fees must
be included in your Application for Licensure packet.
You must complete the Application for Licensure in its entirety, questions numbered 1-37. See
additional instructions below.
You must obtain a 2” x 2” passport style photo. The photo must have been taken within the last 60
days prior to filing your application. Attach the photo to the front of your Application for Licensure as
indicated. Group or cropped photos will not be accepted.
Applicants are required to use live scan, an electronic imaging process that does not require
fingerprint cards. You must complete the enclosed Request for Live Scan Service form and take it
to a local live scan service for processing. You are encouraged to contact the live scan agency
directly to determine if an appointment is necessary and to confirm what method of payment is
accepted. You can view a listing of locations at: https://oag.ca.gov/fingerprints/locations.
Live scan services do not transfer state-to-state therefore are not available for applicants applying
from out of California. If you are applying from out of California, you are required to submit two
completed fingerprint cards and an additional fee of $49. Your local law enforcement agency
should have fingerprint cards available however should you need fingerprint cards, please contact
the Board to have them mailed to you.
All applicants are required to complete a Board-approved Law and Professional Ethics course prior
to licensure. The course can be completed either through the American Association for Respiratory
Care (AARC) or the California Society for Respiratory Care (CSRC). The course can be completed
online or through a live session provided by the CSRC. Only one course is required. Before
deciding which course to take, you are encouraged to visit each provider’s website (www.aarc.org
OR www.csrc.org) to review additional information pertaining to the administration of each course.
Once you complete the course, you must provide a copy of the Certificate of Completion with your
Application for Licensure packet verifying you have successfully completed the mandatory course.
Under certain circumstances, the Board issues applicants a work permit. A work permit allows an
applicant to work under the direct supervision of a licensed respiratory care practitioner. “Under
direct supervision” means that you are assigned to a licensed respiratory care practitioner who is
on duty and immediately available in the assigned patient care area. Any applicant working under a
work permit shall identify him/herself as a “Respiratory Care Practitioner Applicant”. A work permit
will be issued for a period of 90 days to allow you sufficient time to take your examinations and
request your official transcript(s). Work permits will not be extended except in extremely rare
circumstances. A work permit is generally issued within ten days from the time the Board receives:
1) A completed Application for Licensure;
2) The required fingerprint clearances;
If criminal, disciplinary, or substance abuse exists, the Board’s enforcement unit must
determine if a work permit may be issued.
3) Verification of graduation or certification of upcoming graduation on question nine of the
Application for Licensure;
4) Verification of your credential(s) if you have already taken and passed the NBRC exams.
Once the Board receives all required documentation, you will be issued your RCP license. Initial
licenses are issued for a period of 13-24 months depending upon the issuing month of the license
and the applicant’s birth month. After your initial license period, the license must be renewed every
two years to remain current. To continue to hold an active license, you must meet all current
license renewal requirements. If you allow your license to expire, you will have three years from the
expiration date to renew the license or the license becomes canceled and cannot be renewed.
NOTICE ON COLLECTION OF PERSONAL INFORMATION
Collection and Use of Personal Information
The Respiratory Care Board of the Department of Consumer Affairs collected the personal information requested on this form
as authorized by Business and Professions Code sections 30 and 3730 and the Information Practices Act. The Board uses
this information principally to identify and evaluate applicants for licensure, issue and renew licenses, and enforce licensing
standards set by law and regulation.
Mandatory Submission
Submission of the requested information is mandatory. The Board cannot consider your application for licensure or renewal
unless you provide the requested information.
Access to Personal Information
You may review the records maintained by the Board that contain your personal information, as permitted by the Information
Practices Act. See below for contact information.
Possible Disclosure of Personal Information
We make every effort to protect the personal information you provide us. The information you provide, however, may be
disclosed during the following circumstances:
→ In response to a Public Records Act request (Government Code section 6250 and following), as allowed by the
Information Practices Act (Civil Code section 1798 and following);
→ T
o another government agency as required by State or Federal law;
or
→ I
n response to a court or administrative order, a subpoena, or search warrant
.
C
ontact Information
For questions about this notice or access to your records, you may contact the Board at 3750 Rosin Court, Suite 100,
Sacramento, CA 95834, by phone at (916) 999-2190, or by email at rcbinfo@dca.ca.gov
. For questions about the
Department’s Privacy Policy, you may contact the Department of Consumer Affairs at 1625 North Market Boulevard,
Sacramento, CA 95834, by phone at (800) 952-5210, or by email at dca@dca.ca.gov.
DISCLOSURE OF SSN OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
Disclosure of your social security number (SSN) or individual taxpayer identification number (ITIN) is mandatory. Section 30
of the Business and Professions Code and Public Law 94-455 (42 U.S.C.A. 405(c)(2)(C)) authorizes collection of your SSN
or ITIN. Your SSN or ITIN will be used exclusively for tax enforcement purposes, for purposes of compliance with any
judgment or order for family support in accordance with section 11350.6 of the Welfare and Institutions Code, or for
verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and
where licensure is reciprocal with the requesting state. If you fail to disclose your SSN or ITIN, you will be reported to the
Franchise Tax Board, which may assess a $100.00 penalty against you. Further, the Respiratory Care Board is prohibited
from processing any application without a SSN or ITIN. Therefore, if you do not disclose your SSN or ITIN, you will not be
permitted to take the examination or be issued a license to practice respiratory care in the State of California.
REPORTING OF SUSPECTED INSTANCES OF CHILD ABUSE
Section 11166 of the Penal Code requires any childcare custodian, medical practitioner, non-medical
practitioner, or employee of a child protective agency who has knowledge of or observes a child in his or her professional
capacity or within the scope of his or her employment whom he or she knows or reasonably suspects has been the victim of
child abuse to report the known or suspected instance of child abuse to a child protective agency immediately or as soon as
practically possible by telephone and to prepare and send a written report thereof within 36 hours of receiving the information
concerning the incident.
"Health practitioner" includes physician and surgeons, psychiatrists, psychologists, dentists, residents, interns, podiatrists,
chiropractors, licensed nurses, dental hygienists, or any other person who is licensed under Division 2 (commencing with
Section 500) of the Business and Professions Code. RCP's are licensed under Division 2 of the Business and Professions
Code.
EXAM SCHEDULING INFORMATION
All applicants must take and pass all parts of the Registered Respiratory Therapist (RRT) Credentialing
Examination, which includes the Therapist Multiple Choice (TMC) and Clinical Simulation Examination
(CSE), to qualify for licensure in the State of California unless a Certified Respiratory Therapist
credential was earned prior to January 1, 2015. Please note, possessing a CRT and/or RRT
credential does NOT authorize you to practice respiratory care in the State of California, you
must possess a valid license issued by the Respiratory Care Board to practice respiratory care
in the State of California.
Before you apply for your examination you are strongly encouraged to review, in detail, the National
Board for Respiratory Care’s (NBRC) Candidate Handbook. If you request your application for
examination(s) by calling the NBRC, you will receive the handbook with your application. If you apply on-
line or download the application, you can obtain a copy of the handbook by either:
1) Visiting the NBRC’s website at www.nbrc.org. From the home page, click on “Examinations” then
select either “Certified Respiratory Therapist (CRT)” or “Registered Respiratory Therapist (RRT)”.
Then click on “Candidate Handbook” under the Documents tab on the left side.
2) Calling the NBRC at (888) 341-4811 and requesting a handbook be mailed to you.
Filing your Exam Applications
Once you have completed your accredited respiratory education program, you may apply for
examination directly through the NBRC. The first examination you must take is the TMC examination.
The TMC examination is deigned to objectively measure essential knowledge, skills, and abilities
required of entry-level respiratory therapists, as well as determine eligibility for the CSE. There are two
established cut scores for the TMC examination. Candidates may become eligible to take the CSE by
achieving the higher cut score on the TMC examination. Individuals who attempt and pass the TMC
examination at the higher cut score and attempt and pass the CSE will be awarded the RRT credential,
fulfilling the examination requirement for licensure.
Exam Fees
The TMC examination will cost $190 for new applicants and $150 for repeat applicants. The cost for the
CSE is $200 for both new and repeat applicants.
Exam Scheduling
1. Apply and/or Schedule Online
Visit the NBRC’s website to complete an application online. Once you complete the online application
process you will receive a response from the NBRC either notifying you that additional information is
required, or you will be prompted to schedule your examination appointment. Online application
submission is available for all individuals paying the examination fee by credit card (Visa, MasterCard,
American Express, and Discover).
2. Mail your Application Form (THIS IS A TWO-STEP PROCESS)
a. Complete all sections of the application form. Mail or fax it to the NBRC with the required
documentation and examination fee (paid by credit card, personal check, cashier’s check, or
money order) to the address indicated on the form. The NBRC recommends using certified mail as
proof that your application was sent to the NBRC.
Approximately two weeks after receipt by the NBRC, your application will be processed, and a
confirmation notice of eligibility sent. If eligibility cannot be confirmed, a letter explaining why the
application is incomplete will be sent. If you do not receive a confirmation of eligibility or an
incomplete notice from the NBRC within four weeks after mailing your application, contact the
NBRC.
AND
b. The confirmation notice will contain a toll-free telephone number and website address for you to
schedule an examination appointment. This toll-free line is answered from 7:00 a.m. to 9:00 p.m.
(Central Standard Time) on Monday through Thursday, 7:00 a.m. to 7:00 p.m. on Friday, and 8:30
a.m. – 5:00 p.m. on Saturday. Appointments can be scheduled online, 24 hours a day, 7 days a
week.
Eligibility to take the examination will be valid for a period of 90 days. If a candidate fails to schedule an
examination appointment within the 90-day eligibility period, he or she will be required to reapply and
resubmit the application fee.
Examination Testing/Sites
Currently, the TMC and CSE examinations are administered via computer at 28 locations throughout
California: Agoura Hills, Anaheim, Atascadero, Bakersfield, Burbank, Carson, Diamond Bar, El Monte–
Santa Fe Springs, Fresno, Hayward, Imperial, Irvine (2), La Mesa, Lawndale, Modesto (2) , Redding,
Riverside–Mission Grove, Sacramento, San Diego, San Francisco, Santa Clara, Santa Maria, Santa
Rosa, Ventura, Visalia, and Walnut Creek.
Be on time! Candidates who arrive more than 15 minutes after their scheduled testing time will NOT be
admitted. Further, candidates who fail to appear or are more than 15 minutes late to their scheduled
examination time will not be refunded and will be required to submit another application and fee.
To gain admission to the testing site, the candidate needs to present two forms of identification, one with
a current photograph. Both forms of identification must be current and include the candidate’s current
name and signature. One of the forms of identification must be: a driver’s license with photograph, a
state identification card with photograph, a passport, or a military identification card with photograph.
Please note: A temporary driver’s license or any other temporary form of identification (e.g., employment
and student I.D. cards) are not acceptable.
After your identification has been approved, you will be directed to the testing room and assigned to a
testing computer. You will be instructed to enter your Social Security number on the computer screen,
and you will be instructed to capture a photographic image of yourself. This photograph will appear in
the upper right corner of the computer screen during your examination, and it will be printed on your
score report.
Examination Scores
Once you’ve completed your examination, you will be directed to report to the testing site supervisor to
receive your examination scores. All examination scores are transmitted from the NBRC to the Board
within 5 working days. If you fail the examination, you may reapply for examination online at
www.nbrc.org or by submitting a new application (same form used to apply for your initial examination)
and reexamination fee ($150) to the NBRC.
Contact Information:
For EXAM information contact:
National Board for Respiratory Care
10801 Mastin Street, Suite 300
Overland Park, KS 66210
Toll-free: (888) 341-4811
Website: www.nbrc.org
Email: nbrc-info@nbrc.org
APPLICATION FOR LICENSURE FORM INSTRUCTIONS
1.
Applicant Category
I. “Examination Candidate” is an applicant who has not taken and passed all parts of the
NBRC’s RRT examination.
II. “NBRC Credentialed” is an applicant who holds a RRT credential (or CRT credential if
taken before January 2015) by the NBRC.
III. “Education Waiver Candidate” is an applicant who does not meet the current minimum
education requirements but qualifies for an education waiver based on a combination of
prior licensure, education, and/or work experience. For specific waiver criteria, please
see California Code of Regulations section 1399.330.
2. - 8.
Personal Information
Enter all personal information as required except where noted. Disclosure of your Social
Security Number is mandatory. Please disclose all previous name(s), including maiden
name, and dates of use.
9.
Program Director Certification
If you are applying based on an anticipated graduation, this section must be completed,
signed, and dated by your program director. It must also be embossed with the school’s seal.
10.
Completed Respiratory Education Program Information
Enter the name of the institution and date you completed/will complete your approved
respiratory care program. After you have met the education requirements, request your
college or university send “official transcripts” directly to the Board. Be sure the transcripts
will reflect completion of the respiratory care program.
11.
Degree Information
Enter the name of the institution, degree awarded/to be awarded, major, and date you
completed/will complete where you earned your degree(s). After you have met the education
requirements, request your college or university send “official transcripts” directly to the
Board. Be sure the transcripts will reflect the awarding of a minimum of an Associate Degree.
12. - 15.
Other Registrations, Certifications, and Licenses
If you answer yes to questions 12-15, be sure to provide details in the charts below. If you
have already taken and passed the CRT or RRT exam(s) through the NBRC, or hold a
registration, a certificate, or license in any state for any health care profession, you must
contact the issuing agency and request a verification of licensure or credentials be sent
directly to the Board.
16.
Driver’s License Information
If you have been licensed to drive in any state, including California, in the last ten years,
please list the information here.
17. - 24.
Disciplinary and Substance Abuse Questions
Each one of these questions must be answered. If you answer yes to any of these questions,
be sure to complete the applicable chart providing additional details or documentation as
directed.
25. - 37.
Statement of Understanding
Each applicant must read and initial each statement numbered 25-37.
Penalty of Perjury Certification
Each applicant must sign under penalty of perjury that all information contained within the
application and any documentation submitted is true and correct.
RESPIRATORY CARE PRACTITIONER
APPLICATION FOR LICENSURE PACKET
APPLICATION
RESPIRATORY CARE BOARD OF CALIFORNIA
3750 Rosin Court, Suite 100, Sacramento, CA 95834
T: (916) 999-2190 F: (916) 263-7311 W: www.rcb.ca.gov
Respiratory Care Practitioner
APPLICATION FOR LICENSURE
The application fee is $300. A check or money order made payable to the
Respiratory Care Board must be submitted with this application.
If you are submitting fingerprint cards (in lieu of Live Scan), add $49.
Attach a color passport
style 2” x 2” photograph
here.
Photograph must have
been taken within the last
60 days.
Group or cropped
photographs will not be
accepted.
•
Are you the spouse or domestic partner of an active duty member in the armed forces
or the California National Guard?
• Have you ever served or are you currently serving in the United States Military?
• Are you requesting expediting of this application for honorable discharged members of
the U.S. Armed Forces? (DD214 or other supporting documentation is required if “Yes”)
Business and Professions Code section 135.4 provides that the Respiratory Care Board must
expedite, and may assist, the initial licensure process for certain applicants described below.
• Do any of the following statements apply to you?
→ You were admitted to the United States as a refugee pursuant to section 1157 of
title 8 of the United States Code;
→ You were granted asylum by the Secretary of Homeland Security or the United
States Attorney General pursuant to section 1158 of title 8 of the United States
Code; or,
→ You have a special immigrant visa and were granted a status pursuant to section
1244 of Public Law 110-181, Public Law 109-163, or section 602(b) of title VI of
division F of Public Law 111-8, relating to Iraqi and Afghan translators/interpreters
or those who worked for or on behalf of the United States government.
If you selected “Yes,” you must attach evidence of your status as a refugee, asylee, or
special immigrant visa holder
(see below for information regarding acceptable
documentation). Failure to do so may result in application review delays.
ACCEPTABLE DOCUMENTATION
→ Form I-94, Arrival/Departure Record, with an admission class code such as “RE”
(Refugee) or “AY” (Asylee) or other information designating the person a refugee
or asylee.
→ Special immigrant visa that includes the of “SI” or “SQ.”
→ Permanent Resident Card (Form I-551), commonly known as a “Green Card,”
with a category designation indicating that the person was admitted as a refugee
or asylee.
→ An order from a court of competent jurisdiction or other documentary evidence that
provides reasonable assurance that the applicant qualifies for expedited licensure.
Yes
No
Yes
No
Yes
No
Yes
No
Applicant Category (check one)
[Please see instructions. Must meet
waiver criteria set forth in CCR
1.
Examination Candidate
NBRC Credentialed
Education Waiver Candidate
section 1399.330]
Personal Information
2. Name:
Last First Middle Suffix (Jr. etc.)
3. Mailing Address:
Number/Street/Route City State Zip
4. Residence Address:
(If different than above) Number/Street/Route City State Zip
5. Telephone No.: Alternate Telephone No.:
6. E-Mail Address:
7. Date of Birth: Social Security No. or ITIN:
MM DD YYYY (Mandatory)
8. If you have been known by any other name(s), including your maiden name, you must list the full name(s) and
dates of use below. If needed, list additional name(s) and dates of use on a separate sheet of paper and submit
with application.
Full Name: Dates of Use (to/from):
Full Name: Dates of Use (to/from):
Full Name: Dates of Use (to/from):
Program Director Certification
If you will earn your Associate’s Degree and complete your respiratory therapy program within the next 90 days, have
your respiratory care program director complete this section.
9. The undersigned certifies that the records of this institution show that has attended
Student’s Name
and is scheduled to complete his/her respiratory program on
Institution Name
and will have/has met all the requirements for the awarding of an Associate’s Degree on/as of
Date of Completion
(provided all course work currently enrolled in is satisfactory and complete).
Date of Completion
EMBOSS SCHOOL SEAL HERE
I declare under penalty of perjury under the laws of the State of California that the student listed above will complete
our respiratory care program and has met the requirements for the awarding of an Associate’s Degree on the dates
specified above. I understand that should the student not graduate, he/she is ineligible for the licensing examination
and the Board should be notified.
Signed, on the day of ,
Program Director Signature Day Month Year
Education Information
An official copy of your transcript(s) (from each institution if applicable) reflecting completion of your respiratory care
program and the awarding of a minimum of an Associate’s Degree must be sent from the institution directly to the
Board. Please complete both question 10 and 11 regarding education information.
10. Respiratory Education Program Information:
Institution Name: Date (to be) Completed:
11. Degree Information:
(If needed, list additional degree information on a separate sheet of paper and submit with application)
Institution Name: Degree (to be) Awarded:
Major: Date (to be) Awarded:
Institution Name: Degree (to be) Awarded:
Major: Date (to be) Awarded:
Additional Registration, Certification, or License Information
12. Have you previously applied for or been issued a certificate or license with the Respiratory
Care Board of Cal i fornia?
Yes No
13. Have you ever applied for or been issued a registration, certificate, or license to practice
respir atory care in any other state?
Yes No
14. Have you ever applied for or been issued a registration, certificate, or license to practice any
other healing art in California or any other state?
Yes No
15. Have you previously taken the CRT/TMC or RRT credentialing examination or any other
licensing examination?
Yes No
If you answered “Yes” to any question numbered 12-15, you must provide complete information in the following
charts. If needed, list additional information on a separate sheet of paper and submit with application.
(#12-14)
Registration, Certification,
or License Type
Approximate Date of
Application
Approximate Date of
Registration, Certification,
or License Issuance
State or Country where
Registration, Certification,
or License Issued
(#15)
Exam Name or Type Pass ed / Failed Approximate Exam Date
State or Country where
Exam was Taken
If you have ever held a registration, certification, or license in California, or any another state, you must contact the
issuing agency and request a license verification be sent directly to the Board. If you hold a CRT or RRT credential,
you must contact the NBRC and request a credential verification be sent directly to the Board.
Driver’s License Information
16. List all driver’s licenses issued within the last ten years (current or expired). If needed, list additional information
on a separate sheet of paper and submit with application.
License No.: Issuing State: Expiration Date:
License No.: Issuing State: Expiration Date:
License No.: Issuing State: Expiration Date:
Background and Discipline Information
17. Are you required to register as a sex offender in California, or in another state, territory, or
Yes No
under federal law?
Date of Offense: Date of Conviction:
Court of Jurisdiction:
Details:
Profession: State: Date of Incident:
Details:
If you answered yes to any question numbered 19-24, you must also provide with your application official certified
documentation that states the circumstances and outcome of the action.
18. Do you have a medical condition or does your current use of chemical substances in any way
Yes No
impair or limit your ability to conduct, with safety to the public, the practice of respiratory care?
19. Has any disciplinary action ever been taken by any federal, state, or other governmental
agency
or other country against any professional or vocational registration, certificate, or
Yes No
license you now hold or have held in the past?
20. Have you ever been terminated by or resigned from a medical facility or registry in lieu of
disciplinary ac ti on?
Yes No
21. Have you ever been denied a registration, certificate, or license to practice a business or
prof sion by any federal, state, or other governmental agency or other country? es
Yes No
22. Have you ever been denied permission to practice respiratory therapy or any other healing
arts profession by any federal, state, or other governmental agency or other country?
Yes No
23. Have you ever been denied permission to take a registration, certification, or licensing
examination by any federal, state, or other governmental agency or other country?
Yes No
24. Have you ever voluntarily surrendered a license to practice in the healing arts in this state or
any other state?
Yes
No
If you answered “Yes” to any question numbered 19-24, you must provide complete information in the following
chart. If needed, list additional information on a separate sheet of paper and submit with application.
Statement of Understanding (continued to next page)
By initialing the following numbered paragraphs, and by signing the bottom of page four of this application, you certify
under penalty of perjury that you have read and understand this statement of understanding. You have also received
a copy of the current statutes and regulations governing the practice of respiratory care. Further, you understand that
violations of the law, unauthorized or unlawful practice, and misrepresentation are grounds for disciplinary action.
(Initial)
25. The Respiratory Care Board of California (Board) has statutory authority regarding the enforcement and
administration of the Respiratory Care Practice Act (RCPA).
26. N o respiratory car e p r actitioner applicant may begin practice until a valid work permit is ob tained from
the Board.
27. During the application period, the applicant shall be identified as a “Respiratory Care Practitioner
Applicant” and may only practice with a valid work permit while under the direct and immediate
supervision of a licensed respiratory care practitioner.
28. If an applicant fails the Therapist Multiple Choice examination, the work permit becomes invalid exactly
one week from the date the examination was taken.
29. No person who has not been licensed by the Board shall engage in the practice of respiratory care
despite holding a CRT or RRT credential.
30. No person shall engage in the practice of respiratory care or represent himself/herself as such through
verbal claim, sign advertisement, letterhead, business card, badge/name tag, or other representation
unless he or she hold a valid license issued by the Board.
31. On or before the birthday of a licensed practitioner in every other year, following the initial licensure, the
Board shall mail a renewal notice to the latest address of record. A license that is not renewed by the
expiration date becomes invalid and subject to delinquent fees.
32. To renew a license, each respiratory care practitioner shall report compliance with the continuing
education requirement. The license shall not be renewal or reinstated until such verification is received
.
Each licensee may be selected to participate in a random continuing education audit and must provide
evidence of compliance as disclosed.
33. To renew an expired license within three years of the date of expiration, the licensee shall provide
documentation of completion of the required continuing education and pay all past renewal and
delinquent fees. Once a license has expired for three years, the license is deemed cancelled and cannot
be renewed.
34. No person or corporation shall knowingly employ a person who alleges he/she is a respiratory care
practitioner without a license granted under the RCPA.
35. If a licensee has knowledge that another person may be in violation of, or has violated, any of the
statutes or regulations administered by the Board, the licensee shall report this information to the Board
in writing and shall cooperate with the Board in furnishing information or assistance as may be required.
36. Any employer of a respiratory care practitioner shall report to the Board the suspension or termination
for cause of any practitioner in their employ. Suspension or termination for cause is defined to mean
suspension or termination from employment for any of the following reasons:
1) Use of controlled substances or alcohol to such an extent that it impairs the ability to safely
practice respiratory care;
2) Unlawful sale of controlled substances or other prescription
items;
3) Patient neglect, physical harm to a patient, or sexual contact with a patient;
4) Falsification of medical records;
5) Gross incompetence or negligence;
6) Theft from patients, other employees, or the employer.
37. Each applicant and licensee must report, in writing, all changes of address to the Board within 14 days
of su hange. ch
c
Optional Question
Where did you first learn about the respiratory care profession?
(Please check all that apply)
Career Fair
High School
Personal Experience
College
Other
Penalty of Perjury Certification
I declare under penalty of perjury under the laws of the State of California that the information contained in this
application and copies of all documents submitted with the application are true and correct and that I have read and
understand the disclosure statements provided in the directions for this application. I understand that if I do not pass
the Therapist Multiple Choice examination on my first attempt, all rights and privileges to practice as a respiratory care
practitioner applicant automatically cease. I understand that I must possess a valid license to practice respiratory care
in the State of California. I hereby grant the Board permission to verify any information contained in this application.
Applicant’s Signature Date
STATE OF CALIFORNIA
Print Form
Reset Form
DEPARTMENT OF JUSTICE
PAGE 1 of 4
BCIA 8016
(Rev. 04/2020)
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
A0436
LICENSE, CERTIFICATION, PERMIT
ORI (Code assigned by DOJ)
Authorized Applicant Type
RESPIRATORY CARE - 3730 BPC
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
CASGAHP - RESPIRATORY CARE
05323
Agency Authorized to Receive Criminal Record Information
Mail Code (five-digit code assigned by DOJ)
3750 ROSIN COURT, SUITE 100 N/A
Street Address or P.O. Box
Contact Name (mandatory for all school submissions)
SACRAMENTO
CA 95834
(916) 999-2190
City State ZIP Code Contact Telephone Number
Applicant Information:
Last Name
First Name Middle Initial Suffix
Other Name: (AKA or Alias)
Last Name First Name
Suffix
Sex
Male Female
Date of Birth Driver's License Number
Billing
Height Weight Eye Color Hair Color
Number N/A - APPLICANT MUST PAY
(Agency Billing Number)
Misc.
Place of Birth (State or Country) Social Security Number
Number N/A - APPLICANT MUST PAY
(Other Identification Number)
Home
Address
Street Address or P.O. Box City
State ZIP Code
I have received and read the included Privacy Notice, Privacy Act Statement, and Applicant's Privacy Rights.
Date
Applicant Signature
DOJ
FBI
Your Number: N/A
Level of Service:
OCA Number (Agency Identifying Number)
(If the Level of Service indicates FBI, the fingerprints will be used to check the
criminal history record information of the FBI.)
If re-submission, list original ATI number:
Original ATI Number
(Must provide proof of rejection)
Employer (Additional response for agencies specified by statute):
N/A
Employer Name
N/A
N/A
Street Address or P.O. Box
Telephone Number (optional)
N/A
N/A
City State
ZIP Code
Mail Code (five digit code assigned by DOJ)
Live Scan Transaction Completed By:
Date
ATI Number
Name of Operator
Transmitting Agency
LSID
Amount Collected/Billed
STATE OF CALIFORNIA
BCIA 8016
(Rev. 04/2020)
DEPARTMENT OF JUSTICE
PAGE 2 of 4
REQUEST FOR LIVE SCAN SERVICE
Privacy Notice
As Required by Civil Code § 1798.17
Collection and Use of Personal Information. The California Justice Information Services (CJIS)
Division in the Department of Justice (DOJ) collects the information requested on this form as authorized
by Business and Professions Code sections 4600-4621, 7574-7574.16, 26050-26059, 11340-11346, and
22440-22449; Penal Code sections 11100-11112, and 11077.1; Health and Safety Code sections 1522,
1416.20-1416.50, 1569.10-1569.24, 1596.80-1596.879, 1725-1742, and 18050-18055; Family Code
sections 8700-87200, 8800-8823, and 8900-8925; Financial Code sections 1300-1301, 22100-22112,
17200-17215, and 28122-28124; Education Code sections 44330-44355; Welfare and Institutions Code
sections 9710-9719.5, 14043-14045, 4684-4689.8, and 16500-16523.1; and other various state statutes
and regulations. The CJIS Division uses this information to process requests of authorized entities that
want to obtain information as to the existence and content of a record of state or federal convictions to
help determine suitability for employment, or volunteer work with children, elderly, or disabled; or for
adoption or purposes of a license, certification, or permit. In addition, any personal information collected
by state agencies is subject to the limitations in the Information Practices Act and state policy. The DOJ's
general privacy policy is available at http://oag.ca.gov/privacy-policy.
Providing Personal Information. All the personal information requested in the form must be provided.
Failure to provide all the necessary information will result in delays and/or the rejection of your request.
Access to Your Information. You may review the records maintained by the CJIS Division in the DOJ
that contain your personal information, as permitted by the Information Practices Act. See below for
contact information.
Possible Disclosure of Personal Information. In order to process applications pertaining to Live Scan
service to help determine the suitability of a person applying for a license, employment, or a volunteer
position working with children, the elderly, or the disabled, we may need to share the information you give
us with authorized applicant agencies.
The information you provide may also be disclosed in the following circumstances:
•With other persons or agencies where necessary to perform their legal duties, and their use of
your information is compatible and complies with state law, such as for investigations or for
licensing, certification, or regulatory purposes.
• To another government agency as required by state or federal law.
Contact Information. For questions about this notice or access to your records, you may contact the
Associate Governmental Program Analyst at the DOJ's Keeper of Records at (916) 210-3310, by email at
keeperofrecords@doj.ca.gov, or by mail at:
Department of Justice
Bureau of Criminal Information & Analysis
Keeper of Records
P.O. Box 903417
Sacramento, CA 94203-4170
STATE OF CALIFORNIA
BCIA 8016
(Rev. 04/2020)
DEPARTMENT OF JUSTICE
PAGE 3 of 4
REQUEST FOR LIVE SCAN SERVICE
Privacy Act Statement
Authority. The FBI's acquisition, preservation, and exchange of fingerprints and associated
information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application,
supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544,
Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated
information is voluntary; however, failure to do so may affect completion or approval of your
application.
Principal Purpose. Certain determinations, such as employment, licensing, and security clearances,
may be predicated on fingerprint-based background checks. Your fingerprints and associated
information/biometrics may be provided to the employing, investigating, or otherwise responsible
agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's
Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and
latent fingerprint repositories) or other available records of the employing, investigating, or otherwise
responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI
after the completion of this application and, while retained, your fingerprints may continue to be
compared against other fingerprints submitted to or retained by NGI.
Routine Uses. During the processing of this application and for as long thereafter as your fingerprints
and associated information/biometrics are retained in NGI, your information may be disclosed
pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act
of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register,
including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses
include, but are not limited to, disclosures to: employing, governmental, or authorized non-
governmental agencies responsible for employment, contracting, licensing, security clearances, and
other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice
agencies; and agencies responsible for national security or public safety.
STATE OF CALIFORNIA
BCIA 8016
(Rev. 04/2020)
DEPARTMENT OF JUSTICE
PAGE 4 of 4
REQUEST FOR LIVE SCAN SERVICE
Noncriminal Justice Applicant's Privacy Rights
As an applicant who is the subject of a national fingerprint-based criminal history record check for
a noncriminal justice purpose (such as an application for employment or a license, an immigration
or naturalization matter, security clearance, or adoption), you have certain rights which are
discussed below.
• You must be provided written notification1 that your fingerprints will be used to check the
criminal history records of the FBI.
• You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement
when you submit your fingerprints and associated personal information. This Privacy Act
Statement should explain the authority for collecting your information and how your
information will be used, retained, and shared. 2
•If you have a criminal history record, the officials making a determination of your
suitability for the employment, license, or other benefit must provide you the opportunity
to complete or challenge the accuracy of the information in the record.
•The officials must advise you that the procedures for obtaining a change, correction, or
update of your criminal history record are set forth at Title 28, Code of Federal
Regulations (CFR), Section 16.34.
•If you have a criminal history record, you should be afforded a reasonable amount of time
to correct or complete the record (or decline to do so) before the officials deny you the
employment, license, or other benefit based on information in the criminal history record. 3
You have the right to expect that officials receiving the results of the criminal history record check
will use it only for authorized purposes and will not retain or disseminate it in violation of federal
statute, regulation or executive order, or rule, procedure or standard established by the National
Crime Prevention and Privacy Compact Council. 4
If agency policy permits, the officials may provide you with a copy of your FBI criminal history
record for review and possible challenge. If agency policy does not permit it to provide you a copy
of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI.
Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/identity-
history-summary-checks.
If you decide to challenge the accuracy or completeness of your FBI criminal history record, you
should send your challenge to the agency that contributed the questioned information to the FBI.
Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your
challenge to the agency that contributed the questioned information and request the agency to
verify or correct the challenged entry. Upon receipt of an official communication from that agency,
the FBI will make any necessary changes/corrections to your record in accordance with the
information supplied by that agency. (See 28 CFR 16.30 through 16.34.) You can find additional
information on the FBI website at https://www.fbi.gov/about-us/cjis/background-checks.
1
Written notification includes electronic notification, but excludes oral notification
2 https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
3
See 28 CFR 50.12(b)
4
See U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c)
FINAL CHECK OFF LIST
Before you submit your Application for Licensure packet to the Board, please be sure all the following
documentation is attached and/or ordered:
Completed Application for Licensure, including 2” x 2” passport photo attached.
$300 check or money order ($349 with submission of fingerprint cards) included.
Copy of completed Live Scan Form or fingerprint cards (if applying from out of California).
Transcripts (attached in sealed envelope or ordered from institution(s)).
NBRC credential verification(s) ordered from NBRC (if applicable).
Registration/Certification/License verification(s) ordered (if applicable).
Law and Professional Ethics course certificate of completion.
MOST COMMON DEFICIENCIES
Your application will be delayed if any of the required information/documentation is not submitted. The
most common deficiencies are:
→ Failure to complete the Application for Licensure form and respond to each question.
→ Failure to submit appropriate and recent 2” x 2” passport style photo.
Once you have your Application for Licensure packet completed, please mail the packet to the Board at
the address listed below. If you have any questions or concerns regarding the application process, please
visit the Board’s website at www.rcb.ca.gov or contact the Board via phone or email.
Respiratory Care Board of California
3750 Rosin Court, Suite 100
Sacramento, CA 95834
Telephone: (916) 999-2190
Toll Free: (866) 375-0386
Fax: (916) 263-7311
E-mail: rcbinfo@dca.ca.gov
Website: www.rcb.ca.gov
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Respiratory Care Practitioner - Application For Licensure Packet (California)

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Completed 29 November 2021

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