Section R4-26-403. Application for Initial License

A.      An individual who wishes to practice as a behavior analyst and is qualified under A.R.S. § 32-2091.02 shall submit an appli- cation form, which is available from the Board office and on its website, and provide the following information:

1.        Full name;

2.        Other names by which the applicant is or ever has been known;

3.        Home address and telephone number;

4.        Business name and address;

5.        Work telephone and fax numbers;

6.        E-mail address;

7.        Gender;

8.        Date of birth;

9.        Social Security number;

10.     An indication of the address and telephone number to be listed in the agency’s public directory and used in corre- spondence;

11.     Place of birth;

12.     A statement of whether the applicant:

a.         Is or ever has been licensed or certified as a behavior analyst in any regulatory jurisdiction and if so, the jurisdictions and license numbers;

b.        Is or ever has been certified as a behavior analyst by the BACB and if so, the date of original certification and if not, whether the applicant has ever taken the examination required under R4-26-404;

c.         Is or ever has been licensed or certified in other fields or professions and if so, the name of the pro- fessions, regulatory jurisdictions, and license num- bers;

d.        Is or ever has been a member of a hospital staff or provider panel and if so, the name of the hospital or provider and dates of service;

e.         Is or ever has been a member of a professional asso- ciation and if so, the name of the professional asso- ciation and dates of membership;

f.         Has ever had a professional license, certification, or registration    refused,    revoked,    suspended,    or

restricted in any regulatory jurisdiction for reasons relating to unprofessional conduct;

g.        Has ever voluntarily surrendered a license, certifica- tion, or registration, relinquished responsibilities, resigned a position in lieu of termination, or been involuntary terminated in any regulatory jurisdiction while under investigation or in lieu of administrative proceedings for reasons relating to unprofessional conduct;

h.        Has ever resigned or been terminated from a profes- sional organization, hospital staff, or provider panel while a complaint against the applicant was investi- gated or adjudicated;

i.         Is or ever has been under investigation by any pro- fessional organization, health care institution, pro- vider panel of which the applicant is a member or staff, or a regulatory agency in any jurisdiction, including the Arizona Board of Psychologist Exam- iners, concerning the ethical propriety or legality of the applicant’s conduct and if so, the entity doing and dates of the investigation;

j.         Has ever been disciplined by a regulatory agency in any jurisdiction, including the Arizona Board of Psychologist Examiners, health care institution, pro- vider panel, or ethics panel for acts pertaining to the applicant's conduct as a behavior analyst or as a pro- fessional in any field and if so, the regulatory agency, jurisdiction, and date of discipline;

k.        Has ever been convicted of, pled no contest or guilty to, entered into a diversion program to avoid prose- cution, or is under indictment or awaiting trial for a felony or misdemeanor, other than a minor traffic offense, including any conviction that has been expunged, pardoned, reversed, or set aside;

l.         Has ever been sued in a civil court or charged in a criminal court for an act or omission relating to prac- tice as a behavior analyst or work under a license or certificate in another profession, or work as a mem- ber of a profession;

m.       Currently uses alcohol or another drug that in any way impairs or limits the applicant’s ability to prac- tice behavior analysis safely and competently; and

n.        Has a medical, physical, or psychological condition that limits the applicant’s ability to practice behavior analysis safely and competently;

13.     Name and address of every institution of higher learning attended, dates attended, degree received, name of department, and major subject area studied;

14.     Title of graduate degree program;

15.     Name of major advisor and department;

16.     Title of thesis or dissertation, if applicable;

17.     Title of specialty area, if applicable;

18.     A statement of whether:

a.         The graduate program completed was accredited at the time of graduation and if so, the name of the accrediting agency;

b.        The applicant completed a minimum of 225 class- room hours of graduate-level instruction that meet the standards prescribed under R4-26-405; and

c.         The applicant completed degree, coursework, and supervised experience after January 1, 2000, and if so, whether the applicant completed 1,500 hours of supervised experience in the practice of behavior analysis in no less than 12 months; or

d.        The applicant completed degree, coursework, or supervised experience before January 1, 2000, and if so, whether:

i.         The coursework or supervised experience occurred in a setting outside of a college or uni- versity program;

ii.        The coursework or supervised experience was acquired after the graduate degree program and before January 1, 2000; and

iii.      The applicant is certified by the BACB;

19.     A list of the applicant’s supervised experience and the names of individuals the applicant has asked to complete verification forms under subsection (C);

20.     A statement of whether the applicant has completed a minimum of 1,500 hours of  supervised experience in behavior analysis that meets the requirements under A.R.S. § 32-2091.03;

21.     A statement of whether the applicant’s supervised experi- ence included:

a.         Conducting behavioral assessment and assessment activities related to the need for behavioral interven- tions;

b.        Designing, implementing, and monitoring behavior analysis programs for clients;

c.         Overseeing the implementation of behavior analysis programs by others; and

d.        Performing or participating in other activities nor- mally performed by a behavior analyst;

22.     The applicant’s signature attesting that all statements in the application are true in every respect.

B.       Additionally, an applicant shall submit:

1.        An original, un-retouched, passport-quality photograph that is no larger than 1.5 X 2 inches in size and taken no more than 60 days before the date of application;

2.        The application fee required under R4-26-402;

3.        As required under A.R.S. § 41-1080(A), the specified documentation of citizenship or alien status indicating the applicant’s presence in the U.S. is authorized under fed- eral law; and

4.        The Board’s Mandatory Confidential Information form.

C.      Additionally, an applicant shall ensure that the following is submitted directly to the Board:

1.        Verification that the applicant has passed the examination referenced in R4-26-404 submitted by the BACB;

2.        Verification of supervised experience submitted by an individual with direct knowledge of the supervised work experience, independent fieldwork, university practicum, or intensive university practicum;

3.        Official transcripts from all graduate institutions attended submitted by the institutions; and

4.        Verification of licensure, certification, or registration by another regulatory jurisdiction submitted by the regula- tory jurisdiction.

Historical Note

Section made by final rulemaking at 18 A.A.R. 2490, effective September 11, 2012 (Supp. 12-3).