APPLICATION FOR LICENSE TO PROVIDE |
MIDWIFERY SERVICES |
DIVISION OF HEALTH LICENSING |
Pursuant to §40-33-50, §44-1-140, & §44-89-10 of the South Carolina Code Ann. (Suppl. 2001), and Regulation 61-24, licensees and prospective licensees must file an application under oath in order to become eligible for licensure to provide midwifery services and prior to expiration of current license. Midwife licenses are effective for a 24-month period following the date of issue. Apprentice midwife licenses are effective for a 12-month period.
1.Reason for application:
Initial (new) midwife license (complete items 2, 3, 5, 6, and 8).
Initial (new) apprentice midwife license (complete items 2 - 5, and 8).
Renewal of midwife license (complete items 2, 3D, 7, and 8).
Renewal of apprentice midwife license (complete items 2, 3D, 4, 7c, and 8).
_________________________________________________________________________
(Name)
_________________________________________________________________________
(Street address) |
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_________________________________ |
__________________ |
______________ |
(City) |
(County) |
(Zip code) |
c._________________________________________________________________________
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(Mailing address if different) |
(City) |
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(State) |
(Zip code) |
d. |
______________________________ |
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___________________________________ |
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(Home Telephone #) |
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(Business Phone) |
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e. |
________________________ |
Sex: |
Female |
Male |
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(Date of Birth) |
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f._________________________________________
(E-mail Address)
3.a. Have you ever been licensed/certified as a midwife under a different name?
If yes, what name(s)___________________________________________
b.Have you ever held a license or been certified as a midwife or an apprentice in another state?
Yes |
No |
If yes, attach a document depicting state(s), dates held and license number(s). |
c.Have you ever had a midwife license suspended or revoked? Yes No If yes, explain on an attached separate sheet.
d.Have you ever been convicted of any criminal offense other than a minor traffic violation?
Yes No If yes, list offense(s), date(s) of conviction(s), and name and location of court(s) attached on a separate sheet.
4.Attach verification of apprenticeship by your supervisor.
DHEC 252 (05/2007)1[RECORDS RETENTION SCHEDULE #SBH-F&S 17]
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5.Attach documentation required for initial licenses:
a.Official transcript if claiming college or vocational training as source of study or clinical experience.
b.Notarized copies of any current or previous licenses.
c.Two-Step tuberculosis (TB) test result/risk documentation.
6.Attach documentation required for initial licenses:
a.Evidence of completion of midwife course of instruction (subject to approval by Department).
b.Evidence of completed apprenticeship.
c.Certificate of current training for CPR of adults and newborns.
d.Letters of recommendation (to include names, addresses and phone numbers) from:
(1)Professional recommendation from a sponsor indicating applicant is ready to begin practicing.
(2)Professional recommendation from a midwife other than your sponsor.
(3)Personal recommendation from a member of the community.
7.Attach documentation required for renewal licenses:
a.Continuing education.
b.Certificate of current CPR training for adults and newborns for each of two previous years.
c.TB test results/risk documentation (for each of previous two years).
d.Evidence of participation in an annual peer review system.
8.VERIFICATION
State of___________________________________
County of_________________________________
I, _________________________________________________________________________________ do hereby swear or affirm, depose and say that I have read the foregoing application and know the contents thereof, and that the statements therein contained are correct and true to the best of my knowledge.
______________________________________________________________________________
(Signature)
Subscribed and sworn to before me this ______day of____________________, ___________.
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(Month) |
(Year) |
NOTARY PUBLIC_______________________________________________________________ |
My commission expires ____________________ |
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DHEC 252 (05/2007) |
2 |
[RECORDS RETENTION SCHEDULE #SBH-F&S 17] |
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Instructions for Completing DHEC Form 0252
Application for License to Provide Midwifery Services
Division of Health Licensing
PURPOSE: Pursuant to §40-33-50, §44-1-140, & §44-89-10 of the South Carolina Code Ann. (Suppl. 2001), and Regulation 61-24, licensees and prospective licensees must file an application under oath in order to become eligible for licensure to provide midwifery services and prior to expiration of current license. Midwife licenses are effective for a 24-month period following the date of issue. Apprentice midwife licenses are effective for a 12-month period.
INSTRUCTIONS:
Line 1. Check either a,b,c, or d for the reason for submitting this application.
Line 2.a. Enter the name of the full name of the individual to be licensed.
Line 2.b. Enter the location address where the individual to be licensed resides or will conduct their services from.
Line 2.c. Enter the mailing address if different from Line 2.b.
Line 2.d. Enter the home and business telephone numbers of the person listed on Line 2.a.
Line 2.e. Enter the date of birth and check the appropriate block as to whether the person listed on Line 2.a. is male or female.
Line 2.f. Enter the e-mail address, if available, for the person listed on Line 2.a.
Line 3. Check all appropriate boxes that apply and supply the addition information requested.
Line 4. Attach documentation signed by your supervisor to verify that he/she will sponsor you as an apprentice or to verify that you have completed your apprenticeship under his/her supervision.
Line 5. (Self-Explanatory)
Line 6. (Self-Explanatory)
Line 7. (Self-Explanatory)
Line 8. The verification signature must be that of the individual to who the license is being issued. If the license application is being notarized outside of the State of South Carolina, the notary seal of that state in which it is notarized must be affixed to the application. Otherwise, if a notary registered with the State of South Carolina is notarizing the application, the notary seal does not need to be affixed to the application.
Return completed application to:
SCDHEC
Division of Health Licensing
2600 Bull Street
Columbia, South Carolina 29201
OFFICE MECHANICS AND FILING: The original shall be placed in the Master File of the activity in the Division of Health Licensing and kept there in accordance with the most restrictive retention schedule assigned to this document or other documents contained in the file. The most restrictive retention schedule in our Master Files is SBH-F&S-17, which requires documents to be kept for 6 years within Health Licensing. Records are then shipped to the Consolidated Storage Center for retention of not less than twenty-four years before destroying.
DHEC 252 (05/2007)3[RECORDS RETENTION SCHEDULE #SBH-F&S 17]
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