The materials supporting the reinstatement application shall be:

1. (a) A detailed report of the relevant circumstances if any of the answers to the "yes-no" questions described in Phy 308.06(e) are in the affirmative;
2. (b) A completed work history form, described in Phy 402.04(b), provided by the OPLC;

3. (c) An original, not a photocopy, of a criminal offender record report:

   1. (1) Issued by each state where the applicant has resided or been licensed within the past 6 years, providing that such state will:

      1. a. Send the report to the OPLC; or
      2. b. To the applicant for forwarding to the OPLC;
   2. (2) Covering the applicant under their name and any aliases; and
   3. (3) Dated within the 6 months preceding the application for licensure;

4. (d) Unless the information sought is available only on a website, an official letter of verification sent directly to the OPLC from every state which has issued the applicant a license or other authorization to practice physical therapy since the lapse of the New Hampshire license, stating:

   1. (1) Whether the license or other authorization is or was, during its period of validity, in good standing; and
   2. (2) Whether any disciplinary action was taken against the license or other authorization to practice;
5. (e) A written statement that the reinstatement applicant has not engaged in physical therapy in New Hampshire on a volunteer or paid basis since the date that their license ceased to be valid;
6. (f) If applicable to the reinstatement applicant, proof in accordance with Phy 406 of having completed 24 contact hours of continuing education earned within the immediately preceding 2 years of submission of a completed application;
7. (g) If the reinstatement applicant re-took and passed the National Physical Therapy Examination for either physical therapists or for physical therapist assistants in order to meet the requirement in Phy 403.06(b), the applicant's examination scores sent directly to the OPLC by FSBPT;

8. (h) If the reinstatement applicant is eligible for conditional reinstatement, the applicant and the applicant’s supervisor shall complete the “Supervision Form” requiring the following information:

   1. (1) The following is to be completed by the person being supervised:

      1. a. Name of person to be supervised;
      2. b. State the purpose of the supervision;
      3. c. Check the box if the supervision is of an assistant;
      4. d. License number of applicant to be supervised;
      5. e. Place of employment name;
      6. f. Place of employment address, including street number or P.O. box number, city, state, and zip code; and
      7. g. Place of employment phone number;

   2. (2) The following to be completed by the supervisor:

      1. a. Name of supervisor;
      2. b. Profession of supervisor;
      3. c. License number and state of licensure of the supervisor;
      4. d. Place of employment name;
      5. e. Place of employment address, including street number or P.O. box number, city, state, and zip code
      6. f. Place of employment phone number;
      7. g. The site of supervision which is the actual location where the supervision is to take place, including the stie name and location;
      8. h. Site of supervision phone number;
      9. i. Date the supervision is to start and date supervision ended; and

      10. j. The supervisors signature and date of signing under the following attestation:

          “By signing this form, I state that I have read and understood the applicable rules of supervision or order of the Board for supervision, agree to undertake the duties of supervision set forth in the rules or order of the Board, agree to be responsible for the acts and omissions of any person to whom I delegate the duties of supervision, and acknowledge that my own or my delegate’s failure to comply with the rules or order of the Board might result in disciplinary sanctions.”

9. (i) The completed New Hampshire jurisprudence assessment module provided to the applicant by the FSBPT; and
10. (j) Transcripts as described in Phy 304.02(c) if not previously submitted.

Source. #9431, eff 3-19-09; ss by #10402, eff 8-23-13; ss by #12088, eff 1-20-17; ss by #13825, eff 2-17-24 (formerly Phy 403.08)