Ariz. Admin. Code § R9-16-804 - Initial Community Health Workers Application

A. An applicant for a CHW certification shall submit to the Department:

1. An application provided in a Department-provided format that contains:

a. The applicant's name, home address, telephone number, and e-mail address;

b. The applicant's Social Security number, as required under A.R.S. §§ 25-320 and 25-502;

c. Whether the applicant has completed high school or a high school equivalency program;

d. Whether the applicant is or has been certified as a CHW in another state or country;

e. Whether the applicant has ever been convicted of a felony or a misdemeanor involving moral turpitude in this or another state;

f. If the applicant has been convicted of a felony or a misdemeanor involving moral turpitude:

i. The date of the conviction,

ii. The state or jurisdiction of the conviction,

iii. An explanation of the crime of which the applicant was convicted, and

iv. The disposition of the case;

g. Whether the applicant has had a certification or license revoked or suspended by any state within the previous two years;

h. Whether the applicant is currently ineligible for certification or licensure in any state because of a revocation or suspension;

i. Whether any disciplinary action has been imposed by any state, territory or district in this country for an act related to the applicant's practice as a CHW;

j. Whether the applicant agrees to allow the Department to submit supplemental requests for information under A.R.S. § 411075;

k. An attestation that the information submitted is true and accurate; and

l. The applicant's signature and date of signature;

2. If applicable, a list of all states and countries in which the applicant is or has been certified or licensed as a CHW;

3. Documentation of an applicant's conviction of a felony or a misdemeanor involving moral turpitude in this or another state that includes:

a. The date of the conviction,

b. The state or jurisdiction of the conviction,

c. A description of the crime of which the applicant was convicted, and

d. The disposition of the case;

4. If a certificate or license for the applicant has been revoked or suspended by any state within the previous two years, documentation that includes:

a. The date of the revocation or suspension,

b. The state or jurisdiction of the revocation or suspension, and

c. An explanation of the revocation or suspension;

5. If the applicant is currently ineligible for certificate or license in any state because of a revocation or suspension, documentation that includes:

a. The date of the ineligibility for certification or license,

b. The state or jurisdiction of the ineligibility for certification or license, and

c. An explanation of the ineligibility for certification or license;

6. If the applicant has been disciplined by any state, territory, or district of this country for an act related to the applicant's practice as a CHW, documentation that includes:

a. The date of the disciplinary action,

b. The state or jurisdiction of the disciplinary action,

c. An explanation of the disciplinary action, and

d. Any other applicable documents, including a legal order or settlement agreement;

7. Documentation of the applicant's citizenship or alien status that complies with A.R.S. § 41-1080;

8. As applicable, documentation that demonstrates:

a. Nine hundred and sixty hour of paid or volunteer CHW experience in core competencies specified in R9-16-802(B)(3)(a):

i. The applicant's name;

ii. As applicable, the name of each health care facility, licensed health care provider, or contractor for whom core competencies were completed;

iii. Name of the applicant's supervisor and supervisor's title;

iv. The types of core competencies completed for each health care facility, licensed health care provider, or contractor listed in subsection (ii);

v. The dates or range of dates when the core competencies in subsection (iv) were completed;

vi. The number of hours completed for the core competencies listed in subsection (v); and

vii. The supervisor's signature and date of signature;

b. Completion of a CHW certificate program provided by an accredited college and 480 hours of paid or volunteer CHW experience specified in R9-16-802(B)(3)(b) ;

c. Completion of a CHW training program provided by an organization or certified CHW trainer and 480 hours of paid or volunteer CHW experience specified in R9-16-802(B)(3)(c), including:

i. The applicant's name;

ii. The name of the CHW training program attended;

iii. The name of the organization providing the CHW training program;

iv. The types of core competencies completed;

v. The dates or range of dates when the core competencies in subsection (iii) were completed;

vi. The number of hours completed for each core competency completed in subsection (iv); and

vii. The signature of the individual overseeing the instruction of the CHW training program and the date of signature;

d. Completion of a CHR National Training Program specific in R9-16-802(B)(3)(d):

i. Basic training certification and 480 hours of paid or volunteer CHR or CHW experience; or

ii. Advanced training certification and 380 hours of paid or volunteer CHR or CHW experience; and

e. Completion of high school or high school equivalency or higher degree; and

9. A fee specified in R9-16-810.

B. In lieu of the documentation required in (A)(8), an applicant may submit documentation to the Department that includes:

1. The name of each state that issued the applicant a current certification, including:

a. The certification number of each current certification, and

b. The date each current certification was issued;

2. Documentation of the professional certificate or license issued to the applicant by each state in which the applicant holds a professional certificate or license;

3. A statement, signed and dated by the applicant, attesting that the applicant:

a. Has been certified or licensed in another state for at least one year, with a scope of practice consistent with the scope of practice for which certification is being requested;

b. Has met minimum education requirements specified in this Article;

c. Has not voluntarily surrendered a certification or license in any other state or country while under investigation for unprofessional conduct; and

d. Does not have a complaint, allegation, or investigation pending before another regulatory entity in another state or country related to unprofessional conduct.

C. The Department shall review the application and required documentation for certification as a CHW according to R9-16-808 and Table 8.1.

Notes

Ariz. Admin. Code § R9-16-804

New section made by final rulemaking at 28 A.A.R. 2552, effective 11/7/2022.