Section Diet 302.02 - Application Form On a form provided by the board the applicant shall supply the following:
(a) The applicant's full name and maiden or other name, if any; (b) The applicant's home address, business address, email address, business telephone number and home telephone number;(c) The applicant's date of birth;(d) Whether the applicant is male or female or other;(e) Pursuant to 42 USC 666(a) (13) and RSA 161-B: 11, the applicant's Social Security number;(f) The applicant's registration number issued by the CDR, and whether the applicant was registered on or before December 31, 2000;(g) Under the preprinted heading "Educational Background": (1) The applicant's highest relevant degree and the year of the degree;(2) The academic major of the degree; and(3) The name and location of the school granting the degree;(h) Whether the applicant engaged in an internship, practice program or coordinated program;(i) The following information with respect to the answer to (h) above: (1) The name of the internship or program;(2) The address of the internship or program; and(3) The name and telephone number of the contact person for the internship or program;(j) Whether or not the applicant has ever had an application for a license, certificate or other approval to practice as a Dietetic in a jurisdiction other than the state of New Hampshire denied as the result of a failure to be of good character or on any basis that would constitute cause for denial of a license application under RSA 326-H or the rules of the board;(k) Whether or not the applicant has ever had any certification, registration or approval to practice as a Dietetic revoked in any jurisdiction other than the state of New Hampshire as the result of a failure to be of good character or on any basis that would constitute cause for revocation of a license under RSA 326-H or the rules of the board, unless such revocation was reversed or overturned on appeal or unless such license was reinstated;(l) Whether or not the applicant has ever had been convicted of, or pleaded guilty to, a class A felony that has not been annulled or which has not been reversed or overturned on appeal; (m) Whether or not the applicant has, within the preceding 10 years, been found guilty of malpractice or gross misconduct in practice as a Dietetic in this or any other jurisdiction;(n) Whether or not the applicant has ever been found to have obtained, by fraudulent or deceitful means, a license, certification or other approval to practice as a Dietetic in a jurisdiction other than the state of New Hampshire;(o) Whether or not the applicant has ever committed an act that either caused harm to, or placed at risk, the health, safety or welfare of a person or persons under the applicant's care in the applicant's capacity as a dietitian;(p) Whether or not the applicant is aware of any basis for a conclusion by the board that he or she is not of good character or should not otherwise be granted a license to practice as a Dietetic in the state of New Hampshire and, if so, an explanation of those reasons;(q) Whether or not the applicant has ever been permitted to resign from practice in any profession regulated by law in New Hampshire or any other jurisdiction, or has been permitted to surrender a license, certificate or other authorization to practice in any regulated profession, while under investigation for misconduct in the performance of the profession, or while an action was pending against the applicant before any professional licensing, certifying or authorizing body, or before any court, for misconduct in the performance of the profession;(r) Whether or not, to the best of the applicant's knowledge, he or she is currently under investigation by any agency which licenses, certifies or otherwise authorizes the practice of any profession in this or any other jurisdiction;(s) Whether or not there is currently pending against the applicant any disciplinary action before any agency which licenses, certifies, or otherwise authorizes the practice of any profession in this or any other jurisdiction;(t) Whether or not the applicant has ever had any work-related privileges at a hospital or other health care facility denied, made conditional, curtailed, limited, restricted, suspended or revoked;(u) Whether or not the applicant has ever been permitted to resign from employment or to surrender work-related privileges at any hospital or other health care facility while under investigation for any work-related misconduct, or while an action regarding work-related misconduct was pending against the applicant in any court or before any agency which licenses, certifies or otherwise authorizes practice by health care professionals or which regulates hospitals or other health care facilities in this or any other jurisdiction;(v) Whether or not there is presently pending against the applicant any action or complaint of any type relating to misconduct or to the care of a patient at any hospital or health care facility;(w) The applicant's name in print and the applicant's signature on a statement preprinted on the form certifying that: (1) The information provided on the application form and the documentation provided to support the application is true, accurate, complete and unaltered; and(2) The applicant acknowledges that, pursuant to RSA 641:3, knowingly making a false representation on the application form is punishable as a class B misdemeanor; and(x) The date of the signature described in (w) above.N.H. Admin. Code § Diet 302.02
#7772, eff 10-3-02; ss by #8336, eff 5-1-05
Amended byVolume XXXIV Number 46, Filed November 13, 2014, Proposed by #10691, Effective 10/9/2014, Expires10/9/2024.