STATE OF UTAH
DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING
APPLICATION FOR LICENSURE
DIRECT-ENTRY MIDWIFE
APPLICATION INSTRUCTIONS AND INFORMATION
General Statement: The Utah Division of Occupational and Professional Licensing (DOPL)
desires to provide courteous and timely service to all applicants for licensure. To facilitate the
application process, submit a complete application form including all applicable supporting
documents and fees. Failure to submit a complete application and supply all necessary information
will delay processing and may result in denial of licensure. The fees are for processing your
application and will not be refunded. Please read all instructions carefully.
Address of Record: The address you provide on this application will be your address of record.
All correspondence from DOPL will be sent to that address. You are responsible to directly notify
DOPL of any change to your address of record. Do not rely on a forwarding order.
Social Security Number: Your social security number is classified as a private record under the
Utah Government Records Access and Management Act. It is used by DOPL as an individual
identifier. It is also used for child support enforcement pursuant to Subsection 78-32-17(3) and is
mandatory pursuant to Subsection 58-1-301(1), Utah Code Ann., which implements 42 U.S.C.
666(a)(13). If an SSN is not provided, the application is incomplete and may be denied.
SUPPORTING DOCUMENTS AND FEES:
In addition to submitting a completed application, complete the following:
1.
Submit documentation of current certification in good standing as a Certified Professional
Midwife (CPM) with the North American Registry of Midwives (NARM).
2.
Submit documentation of current certification in adult and infant CPR from the American
Heart Association, American Red Cross or its affiliates, or the American Safety and Health
Institute.
3.
Submit documentation of current certification in newborn or neonatal resuscitation from the
American Academy of Pediatrics, American Heart Association, or an MEAC approved
program or accredited school of midwifery.
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4.
Submit official transcripts or a certificate of completion of a pharmacology course from an
MEAC approved midwifery program, school, or course; from a regionally accredited
institution of higher education; or a general pharmacology course from a health-related
course of study.
NOTE: Have the school send the transcript directly to DOPL. You may also have the
school send the transcript to you for inclusion with your application so long as it is in a
sealed envelope, bearing the school’s stamp/seal on the envelope flap.
5.
If you are currently licensed in another state, use the “Request for Verification of License”
form (attached to this application) to obtain verification of licensure from a state in which you
are currently licensed as a direct-entry midwife.
Request that the verifying state complete the form and mail or fax it directly to DOPL.
6.
Submit a $100.00 non-refundable application-processing fee, made payable to “DOPL.”
ADDITIONAL IMPORTANT INFORMATION:
1.
Laws and Rules: You are required to understand all Utah laws and rules pertaining to your
practice as a direct-entry midwife. The following applicable laws and rules are available on
the Internet at www.dopl.utah.gov:
Division of Occupational & Professional Licensing Act
General Rules of the Division of Occupational & Professional Licensing
Health Care Providers Immunity from Liability Act
Direct-Entry Midwife Act
Direct-Entry Midwife Act Rules
2.
Current Documents: Applications, statutes, rules, and forms are occasionally changed. Go
to www.dopl.utah.gov to ensure you have the most recent version of these documents.
3.
Outcome Data: An individual licensed as an LDEM must submit his/her outcome data
electronically to the Midwives Alliance of North America’s (MANA’s) Division of
Research. To register or obtain more information regarding the MANA Statistics Project
contact MANA at www.manastats.org . Mandatory reporting is required from the time
period of 2006 through 2011.
A licensee is required to submit summary outcome data to DOPL for review, reflecting the
time period of July 1 – June 30 of each year. The data is due July 31 of each year.
4.
Certified Professional Midwife Exam: Information regarding the Certified Professional
Midwife Exam may be obtained by contacting the North American Registry of Midwives
(NARM) at www.narm.org . Currently, the certification exam is offered three times a year
in February, August, and October.
5.
License Renewal: All DEM licenses expire September 30 of every odd-numbered year.
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Unlike many other states, Utah’s license renewal schedule is not based on the licensee’s
date of initial licensure. Under Utah’s renewal system, all licenses in each profession expire
as a group on the same day every two years. Therefore, the length of a licensee’s first
renewal cycle depends on how far into the current renewal cycle initial licensure was
obtained. Each renewal cycle thereafter is for a full two years.
Additionally, the fee paid with this application for licensure is an application-processing fee
only. It does not include a renewal fee. Each licensee is responsible to renew licensure
PRIOR to the expiration date shown on the current license. Approximately two months
prior to the expiration date shown on the license, renewal information is disseminated to
each licensee’s last address of record, as provided to DOPL.
6.
License Issuance: License numbers will not be given out over the telephone. Please do not
call DOPL requesting your license number prior to receiving your printed license in the
mail.
7.
Name Change: If you have been licensed by DOPL under any other name, please submit
documentation of your name change (i.e. copy of a marriage license or divorce decree).
8.
Updating Address Information: It is your responsibility to maintain a current address with
DOPL. If your address is incorrect, you will not receive renewal notices or other
correspondence. Address changes can be made online at www.dopl.utah.gov.
9.
Ceremonial Certificate of Licensure: After obtaining your license from DOPL, you can
order a Ceremonial Certificate of Licensure, printed on parchment paper with original
signatures and an embossed gold seal. Order forms can be obtained at www.dopl.utah.gov.
10.
Acceptable Forms of Payment: Licensure fees can be paid by check or money order, made
payable to “DOPL.” Cash and debit/credit cards (American Express, MasterCard, and Visa) are
also accepted in person at DOPL’s main office – but not over the telephone.
11.
Mail Complete Application to:
Division of Occupational & Professional Licensing
P.O. Box 146741
Salt Lake City UT 84114-6741
Division of Occupational & Professional Licensing
By Express Mail 1st Floor Lobby
160 E 300 S
or In Person
Salt Lake City UT 84111-2305
By U.S. Mail
12.
Telephone Numbers:
(801) 530-6628 or
(866) 275-3675 – Toll-free in Utah
13.
Fax Number:
(801) 530-6511
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APPLICATION FOR LICENSURE
DIRECT-ENTRY MIDWIFE
***Please list your full legal name as it appears on your driver’s license, Social Security Card, etc.***
Last Name:
First Name:
Social Security Number:
I certify under penalty of perjury that:
Middle Name:
Maiden Name:
I am a citizen of the United States and I have a valid US Driver License or US State ID.
License/State ID Number:
State:
I am a citizen of the United States currently living outside the United States and do not have a valid US Drivers License or US State ID. Please
attach a legible copy of your valid passport or other documentation to verify you are a legal citizen of the United States.
I am a non-citizen of the United States, who is lawfully present in the United States and I have a valid US Drivers License or US State ID.
License/State ID Number:
State:
I am a non-citizen of the United States, who is lawfully present in the United States and I do not have a valid US Drivers License or US State
ID. Please attach a legible copy of your current and valid government issued document showing evidence of authorization to work in the
United States.
I am a foreign national not physically present in the United States.
Mailing Address:
City:
State:
ZIP:
Male
Phone #:
E-Mail:
Date of Birth:
Female
List all other licenses, registrations, or certifications issued by any state which you now hold or have ever held in any profession. (Use
additional sheets if necessary.)
Profession:
License Number:
Profession:
License Number:
Profession:
License Number:
Profession:
License Number:
Issuing State:
License Status:
Issuing State:
License Status:
Issuing State:
License Status:
Issuing State:
License Status:
Issue Date:
Issue Date:
Issue Date:
Issue Date:
DO NOT WRITE IN THIS SECTION - FOR DIVISION USE ONLY
License/Certificate Number:
Date License/Certificate Approved: ___/___/____
Approved By:
Date License/Certificate Denied: ___/___/____
Denied By:
Reason for Denial/Other Comments:
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AFFIDAVIT and RELEASE AUTHORIZATION
1.
2.
3.
4.
I certify that am qualified in all respects for the license for which I am applying in this application.
I certify that to the best of my knowledge, the information contained in the application and its supporting document(s) is free
of fraud, forgery, misrepresentation, omission of material fact; is truthful, correct, and complete; discloses all material facts
regarding the applicant; and that I will update or correct the application as necessary, prior to any action on my application.
I authorize all persons, institutions, organization, schools, governmental agencies, employers, references, or any others not
specifically included in the preceding characterization, which are set forth directly or by reference in this application, to
release to the Division of Occupational and Professional Licensing, State of Utah, any files, records, or information of any
type reasonably required for the Division of Occupational and Professional Licensing to properly evaluate my qualifications
for licensure/certification/registration by the State of Utah.
I understand that it is the continuing responsibility of applicants and licensees to read, understand, and apply the
requirements contained in all statutes and rules pertaining to the occupation or profession for which you are applying, and
that failure to do so may result in civil, administrative, or criminal sanctions.
Signature of Applicant: ________________________________ Date of Signature: ___ /___ /______
PHARMACOLOGY EDUCATION REQUIREMENT:
(Course must be at least 8 clock hours)
Name of Program:
Dates Attended:
to
Location:
CERTIFIED PROFESSIONAL MIDWIFE CERTIFICATION REQUIREMENT:
Expiration: ___/___/____
Number:
LICENSES:
List all licenses, registrations, or certifications issued by any jurisdiction which you now hold, have
ever held, or have ever applied for in any health care profession. (Use additional sheets if necessary.)
Issuing State:
License Status:
Profession:
License Number:
Issuing State:
License Status:
Profession:
License Number:
Issuing State:
License Status:
DOPL-AP-008 Rev 2011-06-20
Effective Date___/___/____
Effective Date: ___/___/____
Profession:
License Number:
Effective Date: ___/___/____
6
DEM QUALIFYING QUESTIONNAIRE
Answer “yes” or “no” for each question. Do not leave any question blank.
1.
Have you ever applied for or received a license, certificate, permit, or registration to
practice in a regulated profession under any name other than the name listed on this
application?
2.
Have you ever been denied the right to sit for a licensure examination?
3.
Have you ever had a license, certificate, permit, or registration to practice a regulated
profession denied, conditioned, curtailed, limited, restricted, suspended, revoked,
reprimanded, or disciplined in any way?
4.
Have you ever been permitted to resign or surrender your license, certificate, permit,
or registration to practice in a regulated profession while under investigation or while
action was pending against you by any health care professional licensing agency,
hospital or other health care facility, or criminal or administrative jurisdiction?
5.
Are you currently under investigation or is any disciplinary action pending against
you now by any licensing or governmental agency?
6.
Have you ever had hospital or other health care facility privileges denied,
conditioned, curtailed, limited, restricted, suspended, or revoked in any way?
7.
Have you ever been permitted to resign or surrender hospital or other health care
facility privileges, while under investigation or while action was pending against you
by any licensing agency, hospital or other health care facility, or criminal or
administrative jurisdiction?
8.
Is any action related to your conduct or patient care pending against you now at any
hospital or health care facility?
9.
Have you ever had rights to participate in Medicaid, Medicare, or any other state or
federal health care payment reimbursement program denied, conditioned, curtailed,
limited, restricted, suspended, or revoked in any way?
10.
Have you ever been permitted to resign from Medicaid, Medicare, or any other state
or federal health care payment reimbursement program while under investigation or
while action was pending against you by any licensing agency, hospital, or other
health care facility, or criminal or administrative jurisdiction?
(Continued on the next page.)
DOPL-AP-008 Rev 2011-06-20
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11.
Is any action pending against you now by Medicaid, Medicare, or any other state or
federal health care payment reimbursement program?
12.
Have you ever had a federal or state registration to sell, possess, prescribe, dispense,
or administer controlled substances denied, conditioned, curtailed, limited, restricted,
suspended or revoked in any way by either the Federal Drug Enforcement
Administration or any state drug enforcement agency?
13.
Have you ever been permitted to surrender your registration to sell, possess,
prescribe, dispense, or administer controlled substances while under investigation or
while action was pending against you by any health care profession licensing agency,
hospital or other health care facility, or criminal or administrative jurisdiction?
14.
Is any action pending against you now by either the Federal Drug Enforcement
Administration or any state drug enforcement agency?
15.
Have you been named as a defendant in a malpractice suit?
16.
Have you ever had office monitoring, practice curtailments, individual surcharge
assessments based upon specific claims history, or other limitations, restrictions, or
conditions imposed by any malpractice carrier?
17.
Have you ever had any malpractice insurance coverage denied, conditioned,
curtailed, limited, suspended, or revoked in any way?
18.
If you are licensed in the occupation/profession for which you are applying, would
you pose a direct threat to yourself, to your patients or clients, or to the public health,
safety, or welfare because of any circumstance or condition?
19.
Have you ever been declared by any court of competent jurisdiction incompetent by
reason of mental defect or disease and not restored?
20. _____
Have you been terminated from a position because of drug use or abuse within the
past five (5) years?
21. _____
Have you ever had a documented case in which you were involved as the abuser in
any incident of verbal, physical, mental, or sexual abuse?
22.
Are you currently using or have you recently (within 90 days) used any drugs
(including recreational drugs) without a valid prescription, the possession or
distribution of which is unlawful under the Utah Controlled Substances Act or other
applicable state or federal law?
(Continued on the next page.)
DOPL-AP-008 Rev 2011-06-20
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23.
Have you ever used any drugs without a valid prescription, the possession or
distribution of which is unlawful under the Utah Controlled Substances Act or other
applicable state or federal law, for which you have not successfully completed or are
not now participating in a supervised drug rehabilitation program, or for which you
have not otherwise been successfully rehabilitated?
24. _____
Do you currently have any criminal action pending?
25. _____
Have you pled guilty to, no contest to, entered into a plea in abeyance or been
convicted of a misdemeanor in any jurisdiction within the past ten (10) years? Motor
vehicle offenses such as driving while impaired or intoxicated must be disclosed but
minor traffic offenses such as parking or speeding violations need not be listed.
26. _____
Have you ever pled guilty to, no contest to, or been convicted of a felony in any
jurisdiction?
27. _____
Have you, in the past ten (10) years, been allowed to plea guilty or no contest to any
criminal charge that was later dismissed (i.e. plea in abeyance or deferred sentence)?
28. _____
Have you ever been incarcerated for any reason in any federal, state or county
correctional facility or in any correctional facility in any other jurisdiction or on
probation/parole in any jurisdiction?
If you answered “yes” to questions 24, 25, 26, 27, or 28 above, you must submit a
complete narrative of the circumstances that occurred for EACH and EVERY conviction,
plea in abeyance, and/or deferred sentence. You must also attach copies of all applicable
police report(s), court record(s), and probation/parole officer report(s).
If you are unable to obtain any of the records required above, you must submit
documentation on official letterhead from the police department and/or court indicating
that the information is no longer available.
If you have formally expunged a criminal record as evidenced by a court order signed by
a judge, you do not need to disclose that criminal history. Expungement orders must be
sent to the Bureau of Criminal Identification and the FBI to enable the expungement to
be completed and the criminal history eliminated from the records.
If you answered “yes” to any of the above questions, enclose with this application
complete information with respect to all circumstances and the final result, if such has been
reached.
A “yes” answer does not necessarily mean you will not be granted a license; however, DOPL
may request additional documentation if the information submitted is insufficient.
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Division of Occupational and Professional Licensing
160 East 300 South, P.O. Box 146741
Salt Lake City, Utah 84114-6741
FAX: (801) 530-6511
REQUEST FOR VERIFICATION OF LICENSE
(Use this form to verify licensure from another state, if applicable.)
PART 1 - TO BE COMPLETED BY THE APPLICANT:
Complete the first section of the form and submit it to the state that is verifying information for you.
Request that the verifying state complete the form and return it to you for submission with your
application. If a verifying state insists on submitting the verification directly to DOPL, indicate that
fact in the appropriate section of the application.
Applicant Name:
Street Address:
City:
State:
I am requesting licensure in the state of Utah as a
Zip:
Direct-Entry Midwife
I am/have been licensed in your state under the name
My social security number is
My date of birth is
My license number in your state is/was
I have enclosed the necessary license verification fee in the amount of $
Signature of Applicant:
DOPL-AP-008 Rev 2011-06-20
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(Continued on the next page.)
PART 2 - TO BE COMPLETED BY THE VERIFYING AGENCY:
Please furnish the information requested, sign and verify the document, and mail or fax it directly
to DOPL or place the completed form in a sealed envelope, and provide it to the applicant in
person or by mail. The applicant will include the verification of licensure with his/her Utah
application. Thank you.
Name of Verifying State:
Name of Licensee (as it appears in verifying state’s records):
Classification of License Issued:
Current Status:
License Number:
Original Date of Licensure: ___/___/____
Expiration Date: ___/___/____
Continuously Licensed:
Yes No, please explain:
Licensed By:
Exam, Type:
Endorsement, from what state?
Waiver:
Date:
Examination Scores:
Education Required For Licensure:
Disciplinary Action or Pending Disciplinary Action:
No Yes, please provide certified copies of all Petitions, Orders, etc.
Signature:
Title:
Agency:
Date:
(SEAL)
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