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AOTA SPECIALTY CERTIFICATION RENEWAL IN DRIVING and COMMUNITY MOBILITY Occupational Therapist Assistant Candidate Renewal Application American Occupational Therapy Association 4720 Montgomery Lane Bethesda, MD 20814-5320 800-SAY-AOTA, ext. 2838 (Members) 301-652-AOTA, ext. 2838 (Nonmembers and Local) 800-377-8555 (TDD) [email protected] http://www.aota.org/certification

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AOTA SPECIALTY CERTIFICATION RENEWALIN DRIVING and COMMUNITY MOBILITY

Occupational Therapist AssistantCandidate Renewal Application

American Occupational Therapy Association4720 Montgomery Lane

Bethesda, MD 20814-5320800-SAY-AOTA, ext. 2838 (Members)

301-652-AOTA, ext. 2838 (Nonmembers and Local)800-377-8555 (TDD)

[email protected]://www.aota.org/certification

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CONTENTS

Background and Information

Purpose

Benefits of Certification

Authority

Occupational Therapy Code of Ethics and Ethics Standards

Eligibility

Submission Deadlines and Review Period

Application Fee

Application

Part A . Applicant Information

Employment/Volunteer Verification Form

Part B . Reflective Portfolio

Identification of activity choices to provide evidence for criteria

Ethical practice—1 of 3

Ethical practice—2 of 3

Ethical practice—3 of 3

Part C . Goal Status and Reflection

Part D . Self-Assessment

Part E . Professional Development Plan

Completion Guidelines and Attestation

© 2016 The American Occupational Therapy Association, Inc. All rights reserved. 2

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BACKGROUND AND INFORMATIONAOTA Specialty Certification RENEWALIn DRIVING and COMMUNITY MOBILITY

Purpose

Through its Specialty Certification programs, the American Occupational Therapy Association (AOTA) provides formal recognition for practitioners who have engaged in a voluntary process of ongoing professional development and who are able to translate that development into improved client outcomes.

The AOTA certification process recognizes applicants who have carefully designed and systematically completed professional development activities that facilitate achievement of the criteria delineated for a specialized practitioner in the certification area.

Renewal of AOTA Specialty Certification is based on peer-review that includes (1) demonstration of relevant experience, (2) a reflective portfolio, and (3) ongoing professional development. The objectives of Specialty Certification renewal are to recognize and acknowledge increased specialization and/or advanced practice in a certification area and to:

1. Create a community of practitioners who share a commitment to continuing competence and the development of the profession.

2. Facilitate and respond to the future development of best practice, education, and research in occupational therapy.

3. Assist consumers and others in the health care community in identifying practitioners with expertise in recognized areas of practice.

Benefits of Certification Renewal

Clinicians--Personal accomplishment, professional recognition, career advancement Administrators--Career laddering, The Joint Commission and other stakeholders,

marketing Faculty--Models the importance of ongoing professional development and reinforces

the critical examination of clinical practice, which can be extended to support learning opportunities for students.

Authority

Driving and Community Mobility Specialty Certification is awarded by AOTA and is A private program Not awarded or required by federal or state governments Not required as part of the minimum qualifications to work as an occupational therapist

or occupational therapy assistant Voluntary.

Driving and Community Mobility Specialty Certification is awarded to individuals who have demonstrated the capacity for meeting identified criteria that reflect specialized occupational therapy practice in the area of driving and community mobility through a peer-reviewed reflective portfolio process.

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Administration of the program is by the AOTA Board for Advanced and Specialty Certification (BASC) under the auspices of the AOTA Commission on Continuing Competence and Professional Development (CCCPD).

Occupational Therapy Code of Ethics

Articulated within Principle 1 of the Occupational Therapy Code of Ethics is the expectation that occupational therapy practitioners shall maintain competency and provide services that are within their scope of practice. It also reminds us that each practitioner is responsible for maintaining high standards and continuing competence in practice, education, and research (AOTA, 2015).

The Specialty Certification program embodies these ethical principles by offering applicants a way to document and reflect on professional development in which they have engaged, as well as determine future learning needs and plan subsequent professional development activities that will enhance their practice.

ReferenceAmerican Occupational Therapy Association. (2015). Occupational therapy code of ethics (2015). American Journal of Occupational Therapy, 69(Suppl. 3), 6913410030. http://dx.doi.org/10.5014/ajot.2015.696S03

Eligibility

Initial certification in Driving and Community Mobility by AOTA Able to meet regulatory requirements to practice in the state(s) in which they provide

service. Minimum of 2000 hours in the certification area in the past 5 calendar years.1, 2, 3 Verification of employment.

1 Must be as an occupational therapy practitioner at the level for which certification is sought. For example, applicants seeking certification at the occupational therapist level must have accumulated the necessary hours as an occupational therapist, not as an occupational therapy assistant or other type of professional. 2 Hours may include roles in any capacity (e.g., clinician, faculty, administrator) as long as they are relevant to the certification area and occupational therapy.3 Service delivery may be paid or voluntary.

© 2016 The American Occupational Therapy Association, Inc. All rights reserved. 4

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Submission Deadlines and Review Period

Renewal applications will be accepted by the second Wednesday of September and March of each year for all certifications. Eligible candidates will be notified about upcoming deadlines by e-mail.

Applications are peer-reviewed and processed over a 4-month period following the application deadline. Review for September applications occurs October to January; review for March applications occurs April to July.

Applications are confirmed as Approved, Denied, or Clarification Needed. Applications that require minimal clarification will be processed with no additional fee. Applications that require clarification significant enough that the content of the application may be altered will be charged an additional $100 processing fee.

Renewal Application Fee

Specialty Certification: $325.00 (nonrefundable)Applicants must be AOTA members at the time of application and at the time certification is granted. Membership is not required to maintain certification once granted, except at the time of renewal.

© 2016 The American Occupational Therapy Association, Inc. All rights reserved. 5

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DRIVING and COMMUNITY MOBILITY RENWAL APPLICATIONPart A. Applicant Information

Please complete the following information.

APPLICANT INFORMATIONAOTA Member ID

Name (Last, First, MI)

Credentials

Primary E-mail

Home Address

City State ZIP

Home Phone Work Phone

CURRENT LICENSURE If not required by state, please mark “n/a.”State(s) Licensed License Number(s) Expiration Date

If more than 4, please list additional here.

OTHER CERTIFICATIONS

Certifying Agency

Credential Awarded, If

Any

Date of Initial

Certification

Certification Expiration

Date

If more than 4, please list additional here.

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PROFESSIONAL MEMBERSHIPS If more than 4, combine multiples in 1 box.

Organization Name Organization’s Focus/MissionDates of

Membership

If more than 4, please list additional here.

EMPLOYMENT--CURRENT Primary

Employer Name

Dates with Employer

Current Position or Title

Employer Address

City State ZIP

Type of Setting☐ Academic Institution☐ Community-Based Setting☐ Government--Federal☐ Government--Local, State☐ Home Health Agency☐ Long-term Care Facility/SNF☐ Hospital Setting

☐ Military☐ Non-profit Agency☐ Private Industry☐ Private Practice☐ Rehab Facility☐ School System☐ Other (please specify): ____________________

Clients ServedPlease identify the populations served at this setting on which this application is based.

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EMPLOYMENT – CURRENT Secondary, if applicable

Employer Name

Dates With Employer

Current Position or Title

Employer Address

City State ZIP

Type of Setting☐ Academic Institution☐ Community-Based Setting☐ Government--Federal☐ Government--Local, State☐ Home Health Agency☐ Long-term Care Facility/SNF☐ Hospital Setting

☐ Military☐ Non-profit Agency☐ Private Industry☐ Private Practice☐ Rehab Facility☐ School System☐ Other (please specify):

Clients ServedPlease identify the populations served at this setting on which this application is based.

EMPLOYMENT--PAST If there are employers in the past 5 years other than those listed above, please identify below.

Previous Employer Name StateDates With

Previous Employer

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VERIFICATION OF EMPLOYMENT/VOLUNTEER SERVICE

An employment/volunteer verification form is required to provide third-party verification of the required hours (see next page). Applicants may submit as many forms as needed to verify the required hours, and duplication of the form is acceptable if needed for more than one employer.

Instructions for submitting Verification Form: Print the form and have employers(s) complete. Include the form as a scanned document as the first page(s) of either the application or evidence file.

Tracking Hours--It is up to applicants how to track the specifics of their service delivery. We ask only for the employment verification form(s) to be submitted, so be sure that whoever is verifying the information feels comfortable and ethical with whatever tracking system is used.

Self-Employed--Because private practice takes on many different forms, applicants have varying ways in which to handle employment verification. Examples of who might verify the form include

Administrator for a company/organization that contracted with the private practitioner for services

Referral source Business partner or co-owner Accountant for the practice.

If none of the options listed above fit an applicant’s situation, and the applicant has an alternative source for verification to use, the applicant may forward that information for review and approval to [email protected] prior to submitting an application.

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AOTA SPECIALTY CERTIFICATION - RENEWALEmployment/Volunteer Verification Form

Employer: You are being asked to verify employment or delivery of occupational therapy services for someone

who is applying for renewal of Specialty Certification by the American Occupational Therapy Association (AOTA).

Please complete all sections of this form and return it to the applicant so that it can be included in his or her application portfolio.

If you have questions, please contact AOTA at [email protected] or (301) 652-6611, ext. 2838. Thank you for your assistance!

Applicant: Submit only as many forms as needed to verify the required hours of occupational therapy experience.

Duplication of the form is acceptable if more than one employer is completing the form. The form must be submitted as the first page(s) of the electronic portfolio of scanned evidence (e.g.,

portable document format [PDF]) that is submitted in support of the application. The application will not be accepted if materials are submitted separately.

Applicant Name

Certification Sought☐ Driving & Community Mobility☐ Environmental Modification☐ Feeding, Eating, Swallowing

☐ Low Vision☐ School Systems

Name of Facility/Company/Organization

City State

Employment Type:

☐ Full-time☐ Part-time☐ Contract/PRN☐ Volunteer

Applicant Start Date Applicant End Date

VerificationThis employment/volunteer service represents ________ hours within the past 5 calendar years toward the 2,000 hours required as an occupational therapy practitioner in the certification area. This may include roles in any capacity (service delivery, administration, teaching, research) as long as they are relevant to the certification area and occupational therapy.

Name of Person Completing Form (please print)

Signature of person completing form

Job Title Phone Number

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DRIVING and COMMUNITY MOBILITY RENWAL APPLICATIONPART B. Reflective Portfolio

AOTA certification programs focus on continuing competence, or the building of capacity to meet identified criteria. Continuing competence is a component of ongoing professional development or lifelong learning. Applicants are expected to engage in a process of self-appraisal relative to the identified criteria. This involves the deliberate selection of the best supporting evidence that demonstrates applicant’s potential for meeting identified criteria and answers the question, What evidence would best indicate that I meet the criteria for specialized practice?

Submit only 1 activity for each criterion. Complete the required professional development activity form for each activity being submitted.

Items to SubmitA single file (preferably PDF) should include:

1. This Part 1 application form, which also includes criterion 9, Ethical Practice 2. Employment verification form3. Activity Forms for 5 additional criteria4. Any additional evidence as required on the Activity Forms.

Guidelines: For each of the 5 of the 11 criteria selected, choose only 1 of the available options to

submit as part of the application. Activities must have occurred within the 5 years since initial certification and prior to

submitting the application. An activity may not be used to meet more than 1 criterion. For example, a formal

learning activity engaged in for Criterion 1 may not also be used for Criterion 3.

The following page outlines the professional development criteria required for Driving and Community Mobility certification. The criteria are based on the 5 AOTA Standards for Continuing Competence: Knowledge, Critical Reasoning, Interpersonal Skills, Performance Skills, and Ethical Practice (AOTA, 2015).

ReferenceAmerican Occupational Therapy Association. (2015). Standards for continuing competence. American Journal of Occupational Therapy, 69(Suppl. 3), 6913410055. http://dx.doi.org/10.5014/ajot.2015.696S16

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Reflective Portfolio--Professional Development Activities

Instructions: Please indicate which of the 5 criteria in addition to criterion #9 you are submitting as part of this application.

1. Knowledge: Diagnostic Considerations – Demonstrates knowledge of primary and secondary conditions that impact occupational engagement related to driving & community mobility.

2. Knowledge: Assessment – Demonstrates knowledge of relevant evidence specific to assessment in driving & community mobility.

3. Knowledge: Intervention – Demonstrates knowledge of relevant evidence specific to intervention in driving & community mobility.

4. Knowledge: Regulation & Payors – Demonstrates knowledge of laws and regulations relevant to driving & community mobility, including payer sources.

5. Assessment: Performance Skills – Administers standardized assessments as delegated by the supervising occupational therapist specific to driving & community mobility consistently integrating clinical observations.

6. Intervention: Performance Skills – In collaboration with the supervising occupational therapist, performs interventions that are unique to driving & community mobility while integrating impact of varying client factors and contexts.

7. Intervention: Critical Reasoning - In collaboration with the supervising occupational therapist, selects, plans, and modifies interventions in driving & community mobility based on evidence and evaluation data.

8. Psychosocial Critical Reasoning – In collaboration with the supervising occupational therapist, recognizes immediate and long-term implications of psychosocial issues related to conditions clients in driving & community mobility and modifies therapeutic approach and occupational therapy service delivery accordingly.

XRequired

9. Ethical Practice – Identifies ethical implications associated with the delivery of services in driving & community mobility and articulates a process for navigating through identified issues.

10. Establishes Networks – Establishes and collaborates with referral sources and stakeholders so that clients and relevant others may achieve outcomes that support health and participation in the area of driving & community mobility.

11. Advocating for Change – Influences services for clients (person, organization, population) in driving & community mobility through independent or collaborative education or advocacy activities.

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ETHICAL PRACTICE SCENARIO (Part 1 of 3)—Client Based

Criterion 9—Ethical Practice: Client-Based

Identifies ethical implications associated with the delivery of services in driving & community mobility and articulates a process for navigating through identified issues.

Guidelines The applicant identifies ethical implications associated with the delivery of services and articulates a

process for navigating through the identified issues. The applicant shall review the AOTA Code of Ethics and align the dilemma with the ethical principle(s)

that is/are challenged.

Ethical Scenarios

Scenario #1

An 89 year old client is referred to your clinic by her family. During an OT driving evaluation she presented with reasonable reaction time, good judgment, and safe driving skills for on-road assessment. However, family members believe she should no longer be driving due to her age, and they want the OT to recommend driving retirement.

Scenario #2

A client with a right BKA completes a driving evaluation using mechanical hand controls. The OT practitioner recommends 2 additional training sessions for this equipment and provides him with a follow-up schedule. The client calls a week later to cancel the training sessions and informs the OT practitioner that he has been driving with his right prosthesis and no longer needs additional training.

Scenario #3

An 86 year old client lives alone in her home of 40 years. She has advanced macular degeneration and moderate dementia. She was referred to OT for a community mobility evaluation. She has a long history of taking the bus to the hair dresser and local grocery store. She reports multiple recent episodes of getting lost while walking and taking the bus, requiring family to search for her and pick her up. After an evaluation, the OT practitioner recommends supportive transportation (escorted use of the bus and door-to-door services); however, the client questions the additional cost and declines.

1. To which scenario are you responding? _________

2. From the AOTA Code of Ethics, which ethical principle(s) has/have been challenged in this scenario? Select the top ethical principle(s) that apply, up to a maximum of 3.☐ 1. Beneficence☐ 2. Non-maleficence☐ 3. Autonomy

☐ 4. Justice☐ 6. Veracity☐ 7. Fidelity

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3. Describe how you would apply the ethical principles identified above to guide you toward a resolution for the concern noted. (average word guideline—500)

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ETHICAL PRACTICE SCENARIO (Part 2 of 3)—Fiscal & Regulatory

Criterion 9—Ethical Practice: Fiscal & Regulatory

Identifies ethical implications associated with the delivery of services in driving & community mobility and articulates a process for navigating through identified issues.

Guidelines The applicant identifies ethical implications associated with the delivery of services and articulates a

process for navigating through the identified issues. The applicant shall review the AOTA Code of Ethics and align the dilemma with the ethical principle(s)

that is/are challenged.

Ethical Scenarios

Scenario #4

A VIP from your hospital resumes driving after a stroke and has had some recent accidents. The CEO requests that you perform an “off the record” driving assessment. You are told not to generate the report typically required by facility policy, but rather to provide assessment results to the VIP, verbally even if he fails.

Scenario #5

According to the state department of vocational rehabilitation policy, an OT driving specialist should assist clients in identifying 2 vendors to participate in a bidding process for vehicle modifications. One of the local vendors approaches the OT specialist and requests that she select his company along with another specific vendor – who is known for higher rates – so that he can competitively outbid the other vendor for the vocational rehabilitation funding. In return, he will encourage customers to contact her for driver rehabilitation services in preference to other programs in the area.

Scenario #6

An OT specialist in community mobility is contracted by a large transit company to provide consultation services with the potential for additional business pending a satisfactory outcome. The request is to assist with the transition toward accessible transportation for the population in the local region to ensure ADA compliance. Following an environment and policies evaluation, the OT provides a comprehensive list of recommendations and necessary modifications that would ensure ADA compliance. The transit company reviews the list and asks the OT if she can revise it by withholding some of the more costly bus stop design recommendations to help cut construction costs and still have her sign off on ADA compliance documentation.

4. To which scenario are you responding? _________

5. From the AOTA Code of Ethics, which ethical principle(s) has/have been challenged in this scenario? Select the top ethical principle(s) that apply, up to a maximum of 3.☐ 1. Beneficence☐ 2. Non-maleficence☐ 3. Autonomy

☐ 4. Justice☐ 6. Veracity☐ 7. Fidelity

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6. Describe how you would apply the ethical principles identified above to guide you toward a resolution for the concern noted. (average word guideline—500)

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ETHICAL PRACTICE SCENARIO (Part 3 of 3)—Scope of Practice

Criterion 9—Ethical Practice: Scope of Practice

Identifies ethical implications associated with the delivery of services in driving & community mobility and articulates a process for navigating through identified issues.

Guidelines The applicant identifies ethical implications associated with the delivery of services and articulates a

process for navigating through the identified issues. The applicant shall review the AOTA Code of Ethics and align the dilemma with the ethical principle(s)

that is/are challenged.

Ethical Scenarios

Scenario #7

A client with a C-6 spinal cord injury is referred to the OT driver rehabilitation specialist. Based on a comprehensive medical record review, it is obvious this client will need highly technical modifications in a van to drive. The OT does not have the experience or these types of vehicle modifications in her driving program; however, another driver rehabilitation program in the area does. She proceeds with the driving assessment and plans to make driving and equipment recommendations as best as she can.

Scenario #8

An OT practitioner has worked extensively in pedestrian safety programs targeting school children and older adults. He is approached to work with a local school for the blind to train the visually impaired students on orientation and mobility in the community. Even though he has never worked with the blind community, he decides to take the position since it is interesting and pays well.

Scenario #9

An OT driving specialist plans to be away from work for 6 weeks. The administrator wants a staff generalist to cover the program during the specialist’s leave. The specialist is told to provide a 2 day driving orientation (including on road) for the generalist, who does not have any driving rehabilitation experience.

7. To which scenario are you responding? _________

8. From the AOTA Code of Ethics, which ethical principle(s) has/have been challenged in this scenario? Select the top ethical principle(s) that apply, up to a maximum of 3.☐ 1. Beneficence☐ 2. Non-maleficence☐ 3. Autonomy

☐ 4. Justice☐ 6. Veracity☐ 7. Fidelity

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9. Describe how you would apply the ethical principles identified above to guide you toward a resolution for the concern noted. (average word guideline—500)

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DRIVING and COMMUNITY MOBILITY RENWAL APPLICATIONPart C. Goal Status and Reflection

As part of initial certification, applicants are asked to establish a professional development plan related to the certification criteria that they will work on during the 5 years between prior to renewal.

A reflection on goal status ensures that practitioners continue to develop and grow professionally, working toward targeted goals and revising them as warranted. Guidelines

Review the status of goals that were established in the initial certification application. Note if any changes were made to the original goals.

What is the status of these goals? Do you feel the goal – as initially written or modified – was achieved?

Parameters

All goals that were identified in the initial application are addressed, and all goals are identified as having been met or, if there were changes, the rationale for change.

Narrative includes a reflection on the value of goals in helping applicant grow professionally.

Applicant's Reflection on Goals

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DRIVING and COMMUNITY MOBILITY RENWAL APPLICATIONPart D. Self-Assessment

Self-assessment is a formative and dynamic process through which occupational therapy practitioners identify goals for professional development and monitor progress toward goals (Moyers, 2010). Self-assessment answers the question, “What can I do to prepare or increase my capacity for the competency demands of the future?” In the Specialty Certification process applicants will use self-assessment to consider all that they have learned thus far in their achievement of the certification criteria. This self-understanding combined with ideas about the way practice is changing will help applicants determine what they should learn next.

ReferenceMoyers, P. A. (2010). Competence and professional development. In K. Sladyk, K. Jacobs, &

N. MacRae (Eds.), Occupational therapy essentials for clinical competence (pp. 475-484). Thorofare, NJ: Slack.

Guidelines Develop the self-assessment by answering the questions below in a single narrative

as they relate to the certification criteria collectively. Use examples to support the answers.

The average answer is 1,350–3,000 words.

Self-Assessment Questions: Describe your current practice in relation to this certification and how you envision

your practice area changing in the future. Having gone through the certification process, what have you discovered that you

want to learn more about in relation to the competencies required for this certification area?

Applicant's Self-Assessment

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DRIVING and COMMUNITY MOBILITY RENWAL APPLICATIONPart E. Professional Development Plan

Professional development planning in the AOTA certification process requires that applicants develop a plan for learning for the next 5 years related to the certification criteria.

Depending on personal style or the specific criterion selected, goals might emphasize outcome, performance, or process; but it is possible for a goal to include a combination of these elements:

Outcome – what are you trying to achieve? Performance – what task will you complete? Process – what specific actions will you take?

Guidelines

Each goal must include the following qualities: It must be relevant to the identified criterion. For example, an applicant goal to

“learn a new assessment tool” would not be relevant to a criterion that deals with "advancing access to OT services."

It must be measurable. There must be an objective way for the applicant to demonstrate a change toward meeting the goal in the next 5 years.

It must controllable by the applicant. The applicant should be able to meet the goal regardless of the external environment. For example, a goal to "Discharge all patients safely to home" is not something than can be realistically controlled by the applicant.

It should reflect specialty practice. What is unique about the goal that is specific to Driving and Community Mobility versus what a good generalist would be expected to do?

Parameters Establish 3 professional development goals. Do not develop more than 1 goal for a single criterion; 3 different criteria must be

represented. Include strategies, success criteria, and target date for completion in goals, which

should also be relevant to your practice. Write unique goals that do not simply reiterate the criterion. Develop goals that represent your own professional development, not the

development of others (e.g., students, other staff).

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Professional Development Goal 1To which criterion does this goal apply (check 1)?

☒ Knowledge: Diagnostic Considerations☐ Knowledge: Assessment☐ Knowledge: Intervention ☐ Knowledge: Regulation and Payers ☐ Assessment: Performance Skills☐ Intervention: Performance Skills

☐ Intervention: Critical Reasoning☐ Psychosocial Critical Reasoning☐ Ethical Practice☐ Establishes Networks☐ Advocating for Change

Applicant’s Goal 1:

Professional Development Goal 2To which criterion does this goal apply (check 1)?

☐ Knowledge: Diagnostic Considerations☐ Knowledge: Assessment☐ Knowledge: Intervention ☐ Knowledge: Regulation and Payers ☐ Assessment: Performance Skills☐ Intervention: Performance Skills

☐ Intervention: Critical Reasoning☐ Psychosocial Critical Reasoning☐ Ethical Practice☐ Establishes Networks☐ Advocating for Change

Applicant’s Goal 2:

Professional Development Goal 3To which criterion does this goal apply (check 1)?

☐ Knowledge: Diagnostic Considerations☐ Knowledge: Assessment☐ Knowledge: Intervention ☐ Knowledge: Regulation and Payers ☐ Assessment: Performance Skills☐ Intervention: Performance Skills

☐ Intervention: Critical Reasoning☐ Psychosocial Critical Reasoning☐ Ethical Practice☐ Establishes Networks☐ Advocating for Change

Applicant’s Goal 3:

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DRIVING and COMMUNITY MOBILITY RENWAL APPLICATIONCompletion Guidelines and Attestation

Item(s) to Submit

1. The following should be uploaded by the application deadline to the following URL: https://www.filesdirect.com/AOTACertification. A single combined document, preferably PDF, is encouraged.A. Certification Application (this document)B. Employment/Volunteer Verification FormC. Professional development activity formsD. Any additional evidence as required by a particular activity (e.g., CE certificates)

2. Renewal application fee of $325 (submitted separately from application): Credit card: Call (800) SAY-AOTA (800-729-2682) extension 1708

Monday- Friday between 9:00-5:00 Eastern to pay by phone. If no answer, please leave a message and your call will be returned by the end of the week. You will not be considered late. Please do not leave a CC number in the message.

Check: Mail check on or before the application deadline toAttn: Certification - AOTA4720 Montgomery LaneBethesda, MD 20814-3449

Applicant Attestation

I hereby attest that the information provided in this application is my own and that I have complied with all Occupational Therapy Code of Ethics and Ethics Standards, including Beneficence; No maleficence; Autonomy, Confidentiality; Justice; Veracity; and Fidelity. If granted certification, I will not use my credential to represent myself to others beyond the level for which I am qualified.

     Signature (electronic signature acceptable)

     Date

© 2016 The American Occupational Therapy Association, Inc. All rights reserved. 23