Fillable of a Polysomnographic Trainees License Polysomnography Technician - (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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of a Polysomnographic Trainees License Polysomnography Technician - (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 7th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Polysomnography Technician - Temporary License Holder
of a Polysomnographic Trainee’s License
Date:________________________________
Anonrefundableapplicationlingfeeof$100.00andalicensefeeof$150.00(foratotalof$250.00)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8Revised:5/6/11
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)Aof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. StudentLoan
Areyouindefaultinregardtoanystudentloanobligation(s)? Yes No
If“Yes,”youmustobtaindocumentaryevidencethatyouhavereachedanarrangementwiththebankorwiththeentitythatissued
yourstudentloan,fortheeventualrepaymentoftheloan.Youwillnotbeabletoobtainalicenseorcerticateunlessyouprovidethe
requireddocumentsconcerningtheplanforrepaymentofyourstudentloan.
6. 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8
click to sign
signature
click to edit
7. MedicalConditionsQuestions
Questionsathroughfpertaintomedicalconditionsanduseofchemical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those
portionsofthefollowingquestionswhichinquireastotheillegaluseofcontrolleddangeroussubstancesoractivity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applica
tion.
Yourapplicationfor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oftheFifthAmendment,providedthattheAttorneyGeneralrstgrantsyouimmunityaffordedbystatutory
law.(N.J.S.A.45:1-20.)
Forthepurposesofthesequestions,thefollowingphrasesorwordshavethefollowingmeanings:
“Ability to practice as a polysomnography technician”istobeconstruedtoincludeallofthefollowing:
a. Thecognitivecapacitytoexercisethereasonablejudgmentsofapolysomnographytechnicianandtolearnandkeepabreastof
professionaldevelopments;and
b. Theabilitytocommunicatethosejudgmentsandrelatedinformationtoclientsandotherinterestedparties,withorwithoutthe
useofaidsordevices,suchasvoiceampliers;and
c. Thephysicalcapabilitytoperformthedutiesofapolysomnographytechnician,withorwithouttheuseofaidsordevices,such
ascorrectivelensesorhearingaids.
“Medical Condition”includesphysiological,mentalorpsychologicalconditionsordisorders,suchas,butnotlimitedtoorthope
dic,
visual,speechandhearingimpairments,cerebralpalsy,epilepsy,musculardystrophy,multiplesclerosis,cancer,heartdisease,
dia
betes,mentalretardation,emotionalormentalillness,speciclearningdisabilities,H.I.V.disease,tuberculosis,drugaddiction
andalcoholism.
“Chemical substance” is tobeconstrued toincludealcohol, drugs ormedications,including thosetakenpursuant to avalid
pre
scriptionforlegitimatemedicalpurposesandinaccordancewiththeprescriber’sdirection,aswellasthoseusedillegally.
“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twoyears.
“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.
Doyouhaveamedicalconditionwhichinanywayimpairsorlimitsyourabilitytopracticeyourprofessionwithreasonable
skillandsafety? Yes  No
b. Arethelimitationsorimpairmentscausedbyyourmedicalconditionreducedoramelioratedbecauseyoureceiveongoing
treatment(withorwithoutmedications)orparticipateinamonitoringprogram**?
Yes  No Notapplicable
c. Arethelimitationsorimpairmentscausedbyyourmedicalconditionreducedoramelioratedbecauseoftheeldofpractice,
thesettingormannerinwhichyouhavechosentopractice? Yes  No Notapplicable
d. Doesyouruseofchemicalsubstance(s)inanywayimpairorlimityourabilitytopracticeyourprofessionwithreasonableskill
andsafety? Yes  No Notapplicable
e. Haveyoueverbeendiagnosedashavingorhaveyoueverbeentreatedforpedophilia,exhibitionismorvoyeurism?
Yes  No
f. Areyoucurrentlyengagedintheillegaluseofcontrolleddangeroussubstances?(Recallthat“currently”isdenedas“within
thelasttwoyears.”) Yes  No
Ifyouanswered “Yes”to question f,areyou currentlyparticipatingin asupervisedrehabilitation programorprofessional
assistanceprogramwhichmonitorsyouinordertoassurethatyouarenotengagingintheillegaluseofcontrolleddangerous
substances? Yes  No
** Ifyoureceivesuchongoing treatmentorparticipate insuchamonitoringprogram,theBoardwillmakeanindividualized
assessmentofthenature,theseverityandthedurationoftherisksassociatedwithanongoingmedicalconditionsoastodetermine
whetheranunrestrictedlicenseorcerticateshouldbeissued,whetherconditionsshouldbeimposedorwhetheryouarenot
eligibleforlicensureorcertication.
____________________________________________________ ___________________________________
Signatureofapplicant Date
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click to sign
signature
click to edit
8. 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.
9. 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
10. 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
11. 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
12. 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
13. 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
14.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
15. 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.)
16. 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
17. 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
18. 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10through18,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
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Technician Education
1. ProvidethenameoftheAmericanAcademyofSleepMedicine(AASM)Self-StudyModulesCoursethatyoucompletedaswellas
thenameandaddressoftheentitythatofferedthecourse.
_____________________________________________ _________________________________

NameofcourseDatesattended
________________________________________________________________________________________________________________________________________________________________________________
Name
andaddressofentityofferingAASMself-studymodulescourse
2. ArrangefortheAASMtoforwardatranscriptofsuccessfulcompletionoftheA-StepSelf-StudyModulesCoursethatyoucompleted
withinthelastyeardirectlytotheStateBoardofPolysomnography,P.O.Box45051,Newark,NJ07101.
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.

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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.13:44etseq.,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6of8
click to sign
signature
click to edit
click to sign
signature
click to edit
New Jersey Office 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 letters of 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.
Continuation on the reverse side ➨
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
________________________
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 7 of 8
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 7th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Sleep Studies to Qualify for a Temporary License as a Technician
I attest that __________________________________________________ has completed _____________________
(Name of applicant) (Number of studies)
sleep studies as a licensed polysomnographic trainee over the last _________________________ months beginning
(Number of months)
________________ ending _______________ at _____________________________________________________,
(Month, Day, Year) (Month, Day, Year) (Name of facility)
______________________________________________________________, ______________________________,
(Address, City, ZIP Code) (Telephone number)
which is provisionally or fully accredited by the American Academy of Sleep Medicine (A.A.S.M.).
_______________________________________________
Print name of licensed polysomnography technologist
or qualied medical director
_______________________________________________ ____________________________________
Signature of licensed polysomnography technologist Date (Month, Day, Year)
or qualied medical director
_______________________________________________ ____________________________________
License number of licensed polysomnography technologist Date of license expiration (Month, Day, Year)
or qualied medical director
Please note:
N.J.A.C. 13:44L-1.2 denes a “qualied medical director” as a licensed physician who is either eligible for board
certication or is board certied in sleep medicine by the American Board of Sleep Medicine, or a certication board
recognized by the American Board of Medical Specialties which bases its certication in sleep medicine upon the sleep
medicine examination created by the American Board of Internal Medicine, and who acts as the medical director of any:
1. In-patient or out-patient sleep center or laboratory provisionally accredited or fully accredited by the A.A.S.M. or
accredited by a Joint Commission;
2. Ambulatory care facility or general acute care hospital licensed by the Department of Health and Senior
Services;
3. Home health agencies, assisted living residences, comprehensive personal care homes, assisted living programs
and alternate family care sponsor agencies licensed by the Department of Health and Senior Services; or
4. Health care service rms registered with the Division of Consumer Affairs.
N.J.A.C. 13:44L-2.3(a) requires that a licensed polysomnographic trainee applying for a temporary license as a
polysomnographic technician complete at least 50 sleep studies in one or more facilities that are provisionally or fully
accredited by the A.A.S.M. during a period that was at least two months long within the previous year. If you have
completed these sleep studies in more than one facility, submit one form for each facility.
(Attach additional copies as necessary.)
Rev. 10/14
click to sign
signature
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New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 7th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Technician Supervision Form
To be completed by the supervisor of each facility.
A supervisor is dened as a licensed polysomnographic technologist
or a qualied medical director (as dened in N.J.A.C. 13:44L-1.2).
_____________________________________________, who is licensed as a physician or polysomnographic
(Nameofsupervisor)
technologistinNewJersey,willactasprimarysupervisorfor_______________________________________________
(Nameofapplicant)
and is aware that he or she, or another physician or polysomnographic technologist licensed in New Jersey,
shallbecontinuouslyon-siteandavailable,eitheron-siteorthroughvoiceorelectroniccommunicationwhenever
__________________________________________________________isactingasapolysomnographictechnician.
(Nameofapplicant)
_________________________________________________willmaintainarecordofthenameandlicensenumberof
(Nameofsupervisor)
thelicensedphysicianorpolysomnographictechnologistwhoissupervising__________________________________
(Nameofapplicant)
whileheorsheisactingasapolysomnographictechnician.
______________________________________________________________________________________
Printnameofsupervisor Nameofapplicant
______________________________________________________________________________________
Signatureofsupervisor Signatureofapplicant
_____________________________________________________________________________________
Date Date
_______________________________________________
Licensenumberofsupervisor
Facility’sname:_____________________________________________________________________________
Facility’saddress:___________________________________________________________________________

Street CityStateZIPcode
Facility’stelephonenumber:____________________________
(includeareacode)
(Attach additional copies as necessary.)
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of a Polysomnographic Trainees License Polysomnography Technician - (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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