| CheckList Name | Instructions |
|---|
| Application | If this application is not completed within six months, updates of certain sections of the application and supporting documents will be required. If this application is not completed within one year, you will be required to complete a new application and resubmit the application fee. You may not practice in the Commonwealth of Pennsylvania until you have issued a license, certificate, registration, permit or authorization. |
| Application Fee | An application fee of $200.00 is required. Please note that all fees are non-refundable. |
| Child Abuse CE | All health-related licensees/certificate holders and funeral directors are considered “mandatory reporters” under section 6311 of the Child Protective Services Law (23 P.S. § 6311). Therefore, all persons applying for issuance of an initial license or certificate from any of the health-related boards (except the State Board of Veterinary Medicine) or from the State Board of Funeral Directors are required to complete, as a condition of licensure, 3 hours of approved training by the Department of Human Services (DHS) on the topic of child abuse recognition and reporting. After you have completed the required course, the approved provider will electronically submit your name, date of attendance, etc. to the Bureau. For that reason, it is imperative that you register for the course using the information provided on your application for licensure/certification. A list of DHS-approved child abuse education providers can be found on the Department of State Website. |
| Clinical Exam | Applicants who completed an accepted regional examination which would include ADEX, CDCA, CRDTS, CITA, SRTA or WREB must have their examination scores sent directly to the Board from the regional examination testing agency. Note: This would not apply to CDCA exam scores as they are accessible by the Board through CDCA's (formerly NERB) website. |
| CPR Certification | A copy of your current CPR card obtained through the American Red Cross, the American Heart Association or an agency substantially similar approved by the Board. The card must reflect all three components – Infant, Child and Adult CPR. **NOTE** Online CPR certification courses are not accepted by the Board. This requires an upload in order to submit your application. |
| Criminal History Check | Provide a recent Criminal History Records Check (CHRC) from the state police or other state agency that is the official repository for criminal history record information for every state in which you have lived, worked, or completed professional training/studies for the past ten (10) years. The report(s) must be dated within 180 days of the date the application is submitted. For applicants living, working, or completing training/studies in Pennsylvania, your CHRC request will be automatically submitted to the Pennsylvania State Police upon submission of this application. The PATCH fee will be included at checkout. Your PA CHRC will be sent directly to the Board/Commission. You will be notified if additional action is required. For individuals living, working, or completing training/studies outside of Pennsylvania during the past ten (10) years, in lieu of obtaining individual state background checks, you may elect to provide BOTH a state CHRC from the state in which you currently reside, AND your FBI Identity History Summary Check, available at Identity History Summary Checks | Federal Bureau of Investigation.
Please note: For applicants currently living, working, or completing training/studies in California, Arizona, or Ohio: Due to the laws of these states, the Board is not an eligible recipient of CHRC's or your CHRC will not be issued to you for upload to the Board. Please obtain your Federal Bureau of Investigation (FBI) Identity History Summary Check, available at the link noted above. |
| Databank Report | Provide an official notification of information (Self Query) from the National Practitioner Data Bank. Please refer to the NPDB website for additional information. When you receive the "Response to your Self Query," you will need to upload it to your online application. The report will need to be uploaded, where prompted, in order to submit your application. |
| Letter of Good Standing (LOGS) | You must contact the state board(s) where you hold or have ever held a license, certificate, permit, registration or other authorization to practice a health-related profession (whether active or inactive, current or expired) and disciplinary standing. If discipline exists, all relevant orders/documents surrounding the disciplinary action(s) are also required. The letter must be sent directly to the Board from the respective licensing board(s). |
| National Examination | You must contact the Joint Commission on National Dental Examinations of the American Dental Association and request your examination scores to be uploaded to their online portal which will be accessed by the Board when your application is reviewed. |
| Opioid CE | Section9.1(a) of ABC-MAP* requires that all prescribers or dispensers, as defined in Section 3 of ABC-MAP, applying for licensure/approval complete at least 4 hours of Board-approved education consisting of 2 hours in pain management or the identification of addiction and 2 hours in the practices of prescribing or dispensing of opioids. Applicants seeking licensure/approval on or after July1, 2017, must document, within one year from issuance of the licensure/approval, that they completed this education either as part of an initial education program, a stand-alone course from a Board-approved course provider, or a continuing education course from an approved continuing education provider. The 4 hours of Board-approved education needs to be completed only once. See the Board’s website for the Opioid Education Forms and additional information. *The Achieving Better Care by Monitoring All Prescriptions Program Act (ABC-MAP)(Act 191 of 2014, as amended) is available on the Legislature’s website at: 2014 Act 191 |
| Record of Graduation | Complete Section 1 of the education form and forward it to your school, program and/or institution verifying the required education for the specified license type. The school must return the completed form directly to the Board. The form will be available for download and printing once the application has been submitted. |
| Resume Curriculum Vitae | You must submit a curriculum vitae (resume) of your practice activity since graduation through the present. Practice activities should be listed in chronological order, include the name, city and state of the employer, dates of employment (month and year) and a description of the practice activity. If you have not practice during a specific timeframe, "no practice" should be documented. The curriculum vitae must be uploaded to your online application in order to submit your application. |
