Section R4-43-201. Initial Application

A.      An applicant for an initial license to practice as an occupa- tional therapist or an occupational therapy assistant shall sub- mit an application form provided by the Board to the Board’s office. The application and all supporting documentation shall be received by the Board at least 7 days before a Board meet- ing to be considered at that Board meeting.

B.       The initial application form shall be signed by an applicant and include the following information on the applicant:

1.        Applicant’s last name, 1st name, and middle name;

2.        How applicant’s name is to be shown on the licensure certificate;

3.        Other names used;

4.        Social security number;

5.        Residence address;

6.        Alternate mailing address if the residential address is to remain confidential;

7.        The type of license for which applying;

8.        The amount of the application and license fee to be sub- mitted;

9.        Applicant’s American Occupational Therapy Certifica-

tion Board or National Board for Certification in Occupa- tional Therapy, Inc. certification number, date of certification, and the number of times the applicant has taken the national examination;

10.     .   Education;

11.     Professional experience, field work, or both within the last 5 years;

12.     .   Employer’s name, address, and telephone number;

13.     . Current and previous occupational therapy or other pro- fessional license or certification numbers  from  other states and foreign countries and the status of the license or certification;

14.     .  Current and previous disciplinary actions;

15.     Affidavit of applicant.

C.      An applicant shall submit or cause to be submitted on the applicant’s behalf the following:

1.        Application fee;

2.        Written verification received from:

a.        The National Board For Certification In Occupa- tional Therapy, Incorporated or the American Occu- pational Therapy Certification Board of a passing score on the examination administered by these enti- ties; or

b.        Certified letters of good standing issued by each state that has previously issued the applicant an occupational therapy license, provided at least 1 of the states requires standards for licensure equivalent to the requirements for licensure in this Chapter and

A.R.S. §§ 32-3401 et seq.

3.        Recommendation of good moral character from 2 health care professionals on a form that shall include the follow- ing:

a.        Applicant’s last name, 1st name, and middle initial, and other names used by applicant;

b.        Applicant’s mailing address;

c.        Applicant’s American Occupational Therapy Certi- fication Board or the National Board For Certifica- tion In Occupational Therapy certification number;

d.        Period of time the health care professional has known the applicant;

e.        Period of time the health care professional has worked with the applicant;

f.         A statement that the health care professional consid- ers the applicant to be of good moral character;

g.        Address, city, state, and zip code where the health care professional worked with the applicant;

h.        A description of the professional relationship or pro- fessional experience with the applicant and why the health care professional recommends the applicant for an occupational therapy license;

i.         Name, address, and telephone number of the health care professional;

j.         The professional license or certification number and issuing agency of the health care professional;

k.        The health care professional’s signature and date.

D.      An applicant applying for a limited permit shall submit the application and information listed in subsections (B), (C), and this subsection. An Arizona licensed occupational therapist assuming the professional and legal responsibility for supervi- sion of a limited permit applicant shall complete and sign a Direct Supervision Agreement for a Limited Permit form with the Board. The occupational therapist shall file the Direct Supervision Agreement for a Limited Permit form with the Board before the Board shall issue a limited permit. The Direct Supervision Agreement for a Limited Permit form shall con- tain the following:

1.        Applicant’s last name, 1st name, middle name, and other names used by the applicant;

2.        Date the form is completed and signed by the supervising occupational therapist;

3.        Name of the supervising occupational therapist;

4.        Arizona license number of the supervising occupational therapist;

5.        Limited permittee’s employment address;

6.        Supervisor’s mailing address;

7.        Supervisor’s employment address and employment tele- phone number;

8.        Description of supervision;

9.        Signature of the supervising occupational therapist.

E.       The Board shall retain the application and documents filed in support of the application.

F.       If the Board denies an application, the applicant may, within 30 days of service of the notice of denial, make a written request for a hearing to review the Board’s decision. The hear- ing shall be conducted under A.R.S. Title 41, Chapter 6, Arti- cle 10.

G.      In a hearing conducted on a denial of a license, the applicant has the burden of proof.

Historical Note

Emergency rule adopted effective December 12, 1991, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 91-4). Emergency rule adopted again effective March 11, 1992, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 92-1). Emergency rule adopted again effective June 5, 1992, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 92-2). Emergency expired.

Emergency rule adopted again effective September 8, 1992, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 92-2). Adopted with changes effective Octo- ber 14, 1992 (Supp. 92-4). Amended effective September

15, 1994 (Supp. 94-3). Amended by final rulemaking at 5

A.A.R. 1427, effective April 22, 1999 (Supp. 99-2).