Form Ph 3137 – Fill Out and Use This PDF

INSTRUCTIONS

1.Complete this application, have it notarized, enclose a non-refundable check for One Hundred Ten Dollars ($110) payable to the Board of Dispensing Opticians, and mail it to the above address.

2.Attach a notarized photocopy of your birth certificate to the application.

3.Attach a “passport” size photograph taken within the preceding twelve (12) months to the front of the application.

NAME

	First	Middle and/or Maiden	Last
DATE OF BIRTH		SOCIAL SECURITY #

You must put your social security number on this form for the application to be complete. State and Federal law require social security numbers on this application. Tenn Code. Ann. §36-5-1301(a), as authorized by 42 U.S.C. § 405(c)(2)(c)(i). The number will be used to verify your identity, to ask questions about your financial responsibility, and for any other purpose allowed by the state or federal law. When you provide your social security number on this application and sign the form, you are agreeing that Department of Health may use your social security number in furtherance of federal and state law, for example, to complete delinquent fees

CURRENT HOME MAILING ADDRESS:		CURRENT PRACTICE NAME & ADDRESS:

HOME PHONE

WORK PHONE

COMPETENCY INFORMATION

PLEASE ANSWER THE FOLLOWING QUESTIONS. If any answers to the questions in this part are in the affirmative, attach an explanation on a separate sheet. In support of your explanation, the final documents or orders from the issuing states, courts, and/or agencies must be submitted along with this application. For the purpose of these questions, the following phrases or words have the following meanings:

1."Ability to practice as an Apprentice Dispensing Optician" is to be construed to include all of the following:

a.The cognitive capacity to make appropriate diagnosis (if necessary) and exercise reasoned judgment and to learn and keep abreast of development in the field;

b.The ability to communicate those judgments and information to clients and other health care providers, with or without the use of aids or devices, such as voice amplifiers; and

c.The physical capability to perform tasks and procedures required of your profession, with or without the use of aids or devices, such as corrective lenses or hearing aids.

2."Medical Condition" includes physiological, mental or psychological disorders, such as, but not limited to; orthopedic, visual, speech and/or hearing impairment, cerebral palsy, epilepsy, muscular dystrophy, specific learning disabilities, HIV disease, tuberculosis, drug addiction, and alcoholism.

3."Chemical Substances" is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid prescription for legitimate medical purposes and in accordance with the prescriber's direction, as well as those used illegally.

4."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 use of drugs or alcohol may have an ongoing impact on one's functioning as a licensee or within the past two (2) years.

5.“Illegal Use of Controlled Substances" means the use of controlled substances obtained illegally (e.g., heroin or cocaine) as well as the use of controlled substances which are not obtained pursuant to a valid prescription or not taken in accordance with the directions of a licensed health care practitioner.

PH-3137	Page 1	RDA S 836-1
(Rev. 1/13)

	Do you currently have a medical condition which in any way impairs or limits your
	ability	to practice as an Apprentice Dispensing Optician with reasonable skill and		___	___
	safety?
	a.	If yes, are they reduced or ameliorated because you receive ongoing treatment
		(with or without medications) or participate in a monitoring program?		___	___
	b.	If you have any limitations or impairments caused by an existing medical condition,
		are they reduced or ameliorated because of the field of practice, the setting, or the
		manner, in which you have chosen to practice?		___	___
	(If you receive such ongoing treatment or participate in such a monitoring
	program, the Board will make an individual assessment of the nature, the
	severity, and the duration of the risks associated with an ongoing medical
	condition so as to determine whether conditions should be imposed or whether
	you are not eligible for apprenticeship.)
	Do you currently use chemical substances?			___	___
	If yes, do they in any way limit your ability to practice opticianry with reasonable skill
	and safety?			___	___
	Are you currently engaged in the illegal use of controlled substances?			___	___
	If yes, are you currently participating in a supervised rehabilitation program or
	professional assistance program which monitors you in order to assure that you are			___	___
	not engaged in illegal use of controlled substances?
	Have	you ever been diagnosed as having or have you ever been treated	for	___	___
	pedophilia, exhibitionism or voyeurism?
	If you have ever held or applied for a license or certificate to practice as a Dispensing
	Optician in any state, county, or province, was or has it ever been denied,
	reprimanded, suspended, restricted, revoked, otherwise disciplined, curtailed, or			___	___
	voluntarily surrendered under threat of investigation or disciplinary action?
	Have you ever been convicted of a felony or a misdemeanor other than a minor traffic
	violation?			___	___
	Have you ever been rejected or censured by a Professional Association?			___	___
	In relation to the performance of your professional services in any profession:
	a.	Have you ever had a final judgment rendered against you?		___	___
	b.	Have you ever had settlement of any legal action rendered against you?		___	___
	c.	Are there any legal actions pending against you or to which you are a party?		___	___
	If you have ever held a license or certificate in any health care profession, has it ever
	been reprimanded, suspended, restricted, revoked, otherwise disciplined, curtailed, or			___	___
	voluntarily surrendered under threat of investigation or disciplinary action?

PH-3137	Page 2	RDA S 836-1
(Rev. 1/13)

CURRENT AND PREVIOUS OPTICIANRY WORK EXPERIENCE

Checking this box indicates that in your current position you are required to manage and/or provide direct supervision to the licensed optician(s) selected for supervision of your apprenticeship training.

AFFIDAVIT OF APPLICANT

Under penalties of perjury, I declare and affirm that the statements made in this application, including accompanying statements and transcripts are true, complete and correct. I understand that any false or misleading information in or in connection with my application may be cause for denial or loss of my apprenticeship.

I further swear that I have read and understand the statutes and the Rules and Regulations, which were enclosed in the application packet, and agree to abide by them while registered in the apprenticeship program.

Signature of Applicant

Sworn to and subscribed before me this

day of

, _________

		Notary Public
	Commission Expires_____________________________________
		(Notary Seal)
PH-3137	Page 3	RDA S 836-1
(Rev. 1/13)

DIRECT SUPERVISOR FORM

THIS FORM MUST BE COMPLETED BY YOUR CURRENT SUPERVISOR

Per Rule 0480-1-.14(2)(a)-(b): Apprenticeship training must be supervised by a dispensing optician, optometrist, or ophthalmologist who has been licensed in Tennessee or another state for at least three (3) years and whose license to practice in Tennessee is current, undisciplined, unrestricted and unencumbered. (a) The supervisor shall work at the premises where the apprenticeship training is conducted. (b) The supervisor shall provide direct supervision at all times in accordance with T.C.A. § 63-14-103(a) and (f) and rule 0480-01-.01(8).

Full Name of Apprentice: ____________________________________________________________________________________

Name of Supervisor/TN License No.: ___________________________________________________________________________

Licensed to Practice as: _______ Dispensing Optician _______Optometrist _______Ophthalmologist

Business Name/Name of Dispensary Where Training Will Occur: ______________________________________________________

Business Full Address:

Business Phone:

Is the facility equipped with the recommended minimum equipment as stated in Rule 0480-1-.14(6)(c)(1) and (2)? Yes ___ No ___

If not, how will apprentice achieve full training, including optical laboratory work?

Describe the type of facility where the apprentice will train:

List the equipment the apprentice will train on:

List the duties the apprentice will be learning:

I request that

be registered under my supervision.

(Applicant)

I,

, being duly sworn, depose and say that to

(Supervisor)

the best of my knowledge and belief, the statements made in this application are true and correct.

Signature of Supervisor

Subscribed and sworn to before me this the

day of

, 20

.

Signature of Notary Public:

My Commission Expires:

Return this form to:

BOARD OF DISPENSING OPTICIANS

665 Mainstream Drive

Nashville, TN 37243

PH-3137	Page 4	RDA S 836-1
(Rev. 1/13)

ALTERNATE SUPERVISOR FORM

THIS FORM MUST BE COMPLETED BY YOUR ALTERNATE SUPERVISOR

Per Rule 0480-1-.14(5)(a)(1)-(2): A licensed dispensing optician may supervise no more than two (2) apprentices concurrently.

(2)A licensed dispensing optician may provide supervision in the temporary and impermanent absence (a.k.a. alternate supervision) of the supervising licensee to one (1) of the two (2) apprentices being supervised concurrently.

Full Name of Apprentice: _____________________________________________________________________________________

Name of Alternate Supervisor/TN License No.: ____________________________________________________________________

Licensed to Practice as: _______ Dispensing Optician _______Optometrist _______Ophthalmologist

Business Name/Name of Dispensary Where Training Will Occur: ______________________________________________________

Business Full Address:

Business Phone:

Is the facility equipped with the recommended minimum equipment as stated in Rule 0480-1-.14(6)(c)(1) and (2)? Yes ___ No ___

If not, how will apprentice achieve full training, including optical laboratory work?

Describe the type of facility where the apprentice will train:

List the equipment the apprentice will train on:

List the duties the apprentice will be learning:

I request that

be registered under my supervision.

(Applicant)

I,

, being duly sworn, depose and say that to

(Alternate Supervisor)

the best of my knowledge and belief, the statements made in this application are true and correct.

Signature of Alternate Supervisor

Subscribed and sworn to before me this the

day of

, 20

.

Signature of Notary Public:

My Commission Expires:

Return this form to:

BOARD OF DISPENSING OPTICIANS

665 Mainstream Drive

Nashville, TN 37243

PH-3137	Page 5	RDA S 836-1
(Rev. 1/13)

APPRENTICESHIP TRAINING IN OPHTHALMIC DISPENSING

SEMI-ANNUAL EVALUATION FORM

Length of Training Program – Pursuant to T.C.A. §63-14-103(a)(10): The period of apprenticeship training must be a minimum of three (3) Years and must include a total of five thousand two hundred fifty (5,250) hours of full time or part time education and training under qualified supervision.

Semi-annual evaluation periods begin six (6) months from the initial registration and six (6) months thereafter until completion of the required training period. Make as many copies of this form as necessary.

The filing of these forms is mandatory. You will not receive reminders to submit this information. This is your responsibility. If these forms are not filed semi- annually, you will be considered not actively pursuing licensure and your application will be closed and you will be required to reapply and pay all fees.

Once you have completed a total of 5,250 hours of education and training under qualified supervision, you will be sent a letter, an application, instructions for completing a criminal background check, and a copy of the rules and regulations stating that you may apply for licensure. If, for any reason, you are not able to apply for licensure at that time, you are still considered to be in apprenticeship training and semi-annual evaluations forms must continue to be submitted to this office. Failure to do so will result in your apprenticeship file being closed. You will be required to complete a new apprenticeship application, pay the fee, and begin a new period of 3 year apprenticeship training.

Please remember, your apprenticeship date begins the date you receive confirmation from the Board. All 6 month evaluations must reflect these dates. If there is a break, a letter must be issued to the Board stating the reason for the break.

Mail to:	BOARD OF DISPENSING OPTICIANS
	665 Mainstream Drive
	Nashville, TN 37243

Apprentice Name:

Mailing Address:

Home Phone:					Office Phone:
Current Practice Name & Address:
Hours worked per week				Cumulative hours earned since beginning apprenticeship:

Duties listed below should be given percentages of time performed on each during a normal work week. Total percentage must account for 100% of work time. Fill in each line.

	% OF TIME				DUTIES PERFORMED
			Fitting and adjusting lenses to human faces.
			Fitting contact lenses.
			Interpreting prescriptions and making optical calculations.
			Verifying.
			Optical laboratory work.
			Selling merchandise (Other than ophthalmic materials.)
			Stock work.
			Office work.
			Describe other duties not listed.
Direct/Alternate Supervisor’s Signature/Title:								Date:
Evaluation period began:						and ended on

AFFIDAVIT OF APPLICANT

Under penalties of perjury, I declare and affirm that the statements made in this application, including accompanying statements and transcripts are true, complete and correct. I understand that any false or misleading information in or in connection with my application may be cause for denial or loss of my apprenticeship.

I further swear that I have read and understand the statutes and the Rules and Regulations, which were enclosed in the application packet, and agree to abide by them while registered in the apprenticeship program.

Signature of Applicant______________________________________________________________________

Sworn to and subscribed before me this _____ day of _________, 20___.
Notary Public__________________________________________
Commission Expires_____________________________________	(Notary Seal)
MS/G4017188/DPO

PH-3137	Page 6	RDA S 836-1
(Rev. 1/13)