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PHYSICAL REHABILITATION BOARD CERTIFICATION Occupational Therapist Table of Contents: ACTIVITY EVIDENCE FORMS Guidelines: Applicant must address criterion 14, as well as 5 additional criteria of their choosing by selecting one (1) available option for each. Please note that the term “ensures” can refer to direct service delivery or the supervision or teaching of others. Reflections should demonstrate advancement in professional development from initial certification. Instructions: Please complete 1 form for each criterion. Combine completed forms in a single document (e.g., Word or .PDF) and submit with the completed Part 1 application to https://www.filesdirect.com/AOTACertification Please do not include unused forms. Criterion 1: Knowledge: Lifespan & Conditions AOTA Certification Application Reviewer Expert Witness Formal Learning (Min. 10 contact hours needed) Independent Learning (Min. 10 contact hours needed) Mentee (does not include supervisory relationship) Publication – Reviewed by Expert(s) Criterion 2: Knowledge: Evaluation AOTA Certification Application Reviewer Expert Witness Formal Learning (Min. 10 contact hours needed) Independent Learning (Min. 10 contact hours needed) Mentee (does not include supervisory relationship) Publication – Reviewed by Expert(s) Criterion 3: Knowledge: Intervention AOTA Certification Application Reviewer Expert Witness Formal Learning (Min. 10 contact hours needed) Independent Learning (Min. 10 contact hours needed) Mentee (does not include supervisory relationship) Publication – Reviewed by Expert(s) Criterion 4: Knowledge: Systems AOTA Certification Application Reviewer Expert Witness Formal Learning (Min. 3 contact hours needed) Independent Learning (Min. 3 contact hours needed) Mentee (does not include supervisory relationship) Publication – Reviewed by Expert(s) Criterion 5: Evaluation: Uses Relevant Evidence Analysis of Recording or Observation Case Study Program Development Research Criterion 6: Evaluation: Prioritizes Needs Case Study Formal Specialized Consultation for Evaluation Program Development Research Criterion 7: Intervention: Design & Implementation Analysis of Recording or Observation Case Study, Client-Based Case Study, Instructional Formal Specialized Consultation for Intervention Mentee (not supervisory relationship) Program Development Research Criterion 8: Intervention: Wellness & Prevention Analysis of Recording or Observation Case Study, Client-Based Case Study, Instructional Formal Specialized Consultation for Intervention Mentee (not supervisory relationship) Program Development Research Criterion 9: Outcomes © 2016 The American Occupational Therapy Association, Inc. All rights reserved.

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Page 1: PHYSICAL REHABILITATION BOARD CERTIFICATION - Web viewServe as a reviewer for 3 AOTA Board Certification applications in physical ... (average word guideline – 200) ... evidence

PHYSICAL REHABILITATION BOARD CERTIFICATIONOccupational Therapist

Table of Contents: ACTIVITY EVIDENCE FORMS

Guidelines: Applicant must address criterion 14, as well as 5

additional criteria of their choosing by selecting one (1) available option for each.

Please note that the term “ensures” can refer to direct service delivery or the supervision or teaching of others.

Reflections should demonstrate advancement in professional development from initial certification.

Instructions: Please complete 1 form for each criterion. Combine completed forms in a single document

(e.g., Word or .PDF) and submit with the completed Part 1 application to https://www.filesdirect.com/AOTACertification

Please do not include unused forms.

Criterion 1: Knowledge: Lifespan & Conditions AOTA Certification Application Reviewer Expert Witness Formal Learning (Min. 10 contact hours needed) Independent Learning (Min. 10 contact hours needed) Mentee (does not include supervisory relationship) Publication – Reviewed by Expert(s)

Criterion 2: Knowledge: Evaluation AOTA Certification Application Reviewer Expert Witness Formal Learning (Min. 10 contact hours needed) Independent Learning (Min. 10 contact hours needed) Mentee (does not include supervisory relationship) Publication – Reviewed by Expert(s)

Criterion 3: Knowledge: Intervention AOTA Certification Application Reviewer Expert Witness Formal Learning (Min. 10 contact hours needed) Independent Learning (Min. 10 contact hours needed) Mentee (does not include supervisory relationship) Publication – Reviewed by Expert(s)

Criterion 4: Knowledge: Systems AOTA Certification Application Reviewer Expert Witness Formal Learning (Min. 3 contact hours needed) Independent Learning (Min. 3 contact hours needed) Mentee (does not include supervisory relationship) Publication – Reviewed by Expert(s)

Criterion 5: Evaluation: Uses Relevant Evidence Analysis of Recording or Observation Case Study Program Development Research

Criterion 6: Evaluation: Prioritizes Needs Case Study Formal Specialized Consultation for Evaluation Program Development Research

Criterion 7: Intervention: Design & Implementation

Analysis of Recording or Observation Case Study, Client-Based Case Study, Instructional Formal Specialized Consultation for Intervention Mentee (not supervisory relationship) Program Development Research

Criterion 8: Intervention: Wellness & Prevention Analysis of Recording or Observation Case Study, Client-Based Case Study, Instructional Formal Specialized Consultation for Intervention Mentee (not supervisory relationship) Program Development Research

Criterion 9: Outcomes Formal Specialized Consultation for Outcomes Program or Service Evaluation & Recommendation Research

Criterion 10: Holistic Practice Case Study, Holistic Practice Program Development Program or Service Evaluation & Recommendation

Criterion 11: Advocating for Change Advocacy Efforts Case Study, Advocacy Volunteer Leadership

Criterion 12: Establishes Networks & Resources Case Study, Networking

Criterion 13: Service to BASC Documentation of Service

Criterion 14: Ethical Practice The 3 ethical practice scenarios are found within

Part I of the application.

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

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AOTA CERTIFICATION APPLICATION REVIEWERBack to Criteria

Criterion 1–Knowledge: Lifespan & ConditionsDemonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.

Guidelines Complete required training for reviewers at the time of the review period, or once every 2

application cycles if reviewing more than once per year. Serve as a reviewer for 3 AOTA Board Certification applications in physical rehabilitation in the last 5 years.

1. Please verify activity information:

Date(s) of reviewer training

Date(s) of application review

Total number of applications reviewed

2. Describe how the knowledge acquired from this activity helped you “demonstrate acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your outcomes? (average word guideline–350)

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

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EXPERT WITNESSBack to Criteria

Criterion 1–Knowledge: Lifespan & ConditionsDemonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.

Guidelines Serving as an expert witness in a civil or criminal legal case court or in arbitration. Providing expert testimony in official hearings at the local, state, or national level.

1. Describe the expertise which you were able to share relevant to physical rehabilitation. (average word guideline–200)

2. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

3. Submit verification of activity as a separate attachment. May include any 1 of the following: Transcript of the testimony. Notice of deposition. Letter from the attorney.

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

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FORMAL LEARNINGBack to Criteria

Criterion 1–Knowledge: Lifespan & ConditionsDemonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.

Guidelines Minimum of 10 contact hours required. Multiple activities may be used to meet the hour requirement for the criterion. Learning must have occurred in the past 5 years.

Please identify the type of activity in which you participated:☐ AOTA CE: Participation in CE course from AOTA. Does not include courses from AOTA Approved

Providers. Completion of course will be verified by AOTA. Submission of additional documentation beyond this form not required.

☐ Non-AOTA CE: Attending workshops, seminars, lectures, or professional conferences with formal established objectives.

☐ Participation in post-professional academic coursework. Attach unofficial transcript.

1. Activity information.

Activity Title

Provider/Instructor

Activity Date(s)

No. of Contact Hours

2. Activity Learning Objectives. List up to 5.

A)

B)

C)

D)

E)

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

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3. Describe the relevance of the activity to your practice in physical rehabilitation. (average word guideline–200)

4. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

5. Submit documentation that verifies completion of the activity, such as certificate of completion or unofficial transcript. Not required for AOTA courses.

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

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INDEPENDENT LEARNINGBack to Criteria

Criterion 1–Knowledge: Lifespan & ConditionsDemonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.

Guidelines Minimum of 10 contact hours required. Multiple activities may be used to meet the hour requirement for the criterion. Learning must have occurred in the past 5 years.

Please identify the type of independent learning activity in which you participated:☐ Independent reading of recent peer-reviewed, professional articles, or chapters in textbook not

associated with a formal learning course. ☐ Independent review of professional electronic resources (e.g., NIH, CDC, CanChild).☐ AOTA Journal Club Toolkit (reading & discussion time). Must be AOTA member to access the kit.☐ AOTA Critically Appraised Paper (CAP, includes submission to the AOTA Evidence Exchange).

1. Why did you choose this activity?☐ Clinical reference for specific population, program, or individual ☐ Invited peer review of scholarly work or publication (print or online)☐ Preparation for poster or presentation ☐ Preparation for academic lecture☐ Literature review for research project☐ Preparation for serving as a mentor☐ Other, please specify:

2. Bibliography (APA Format) or list and objectives of select item(s) used for independent learning.

3. Date(s) of independent learning

4. Time spent engaged in independent learning. For reading, estimate 8–12 published pages/hour. For journal club, discussion time counts toward 10-hour requirement.

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

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5. Describe the relevance of the independent learning activity to your practice in physical rehabilitation. (average word guideline–200)

6. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

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

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MENTEEBack to Criteria

Criterion 1–Knowledge: Lifespan & ConditionsDemonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.

Guidelines Must represent a minimum of 10 hours over a minimum of 2 months. Does not include supervisory relationships. Relationship must have occurred in the past 5 years. May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.

1. Dates of mentoring relationship

2. Approximately how many hours did this represent in total?

3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application. List no more than 3.

A)

B)

C)

4.Mentor

Position/Role of Mentor

Workplace of MentorContact Information for Mentor (email or phone number)

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

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5. State why the mentor was selected to help you meet the goals identified above relative to the criterion. (average word guideline–50)

6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice specific to your ability to “demonstrate acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.” (average word guideline–200)

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

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PUBLICATION – REVIEWED BY EXPERT(S)Back to Criteria

Criterion 1–Knowledge: Lifespan & ConditionsDemonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.

Guidelines Examples of publication reviewed by experts include journals such as AJOT or OTJR. May include a chapter in an occupational therapy or related professional textbook, if chapter has

gone through peer review (a process in which subject matter experts, using a formal system and defined guidelines, provide content guidance to an author and recommend publication, revision, or rejection of a work).

1. Submit APA reference for the publication. For in-press publication, also include a verification letter or e-mail identifying applicant and anticipated date of publication.

2. If applicant is not identified as first or second author, please describe your contribution/involvement in the development of the publication. (average word guideline–200)

3. Provide a reflection indicating why this publication was chosen to represent “knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to physical rehabilitation.” (average word guideline–200)

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

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AOTA CERTIFICATION APPLICATION REVIEWERBack to Criteria

Criterion 2–Knowledge: EvaluationDemonstrates acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.

Guidelines Complete required training for reviewers at the time of the review period, or once every 2

application cycles if reviewing more than once per year. Serve as a reviewer for 3 AOTA Board Certification applications in physical rehabilitation in the

last 5 years.

1. Please verify activity information:

Date(s) of reviewer training

Date(s) of application review

Total number of applications reviewed

2. Describe how the knowledge acquired from this activity helped you “demonstrate acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your outcomes? (average word guideline–350)

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

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EXPERT WITNESSBack to Criteria

Criterion 2–Knowledge: EvaluationDemonstrates acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.

Guidelines Serving as an expert witness in a civil or criminal legal case court or in arbitration. Providing expert testimony in official hearings at the local, state, or national level.

1. Describe the expertise which you were able to share relevant to physical rehabilitation. (average word guideline–200)

2. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

3. Submit verification of activity as a separate attachment. May include any 1 of the following: Transcript of the testimony. Notice of deposition. Letter from the attorney.

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

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FORMAL LEARNINGBack to Criteria

Criterion 2–Knowledge: EvaluationDemonstrates acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.

Guidelines Minimum of 10 contact hours required. Multiple activities may be used to meet the hour requirement for the criterion. Learning must have occurred in the past 5 years.

Please identify the type of activity in which you participated:☐ AOTA CE: Participation in CE course from AOTA. Does not include courses from AOTA Approved

Providers. Completion of course will be verified by AOTA. Submission of additional documentation beyond this form not required.

☐ Non-AOTA CE: Attending workshops, seminars, lectures, or professional conferences with formal established objectives.

☐ Participation in post-professional academic coursework. Attach unofficial transcript.

1. Activity information.

Activity Title

Provider/Instructor

Activity Date(s)

No. of Contact Hours

2. Activity Learning Objectives. List up to 5.

A)

B)

C)

D)

E)

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

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3. Describe the relevance of the activity to your practice in physical rehabilitation. (average word guideline–200)

4. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

5. Submit documentation that verifies completion of the activity, such as certificate of completion or unofficial transcript. Not required for AOTA courses.

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

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INDEPENDENT LEARNINGBack to Criteria

Criterion 2–Knowledge: EvaluationDemonstrates acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.

Guidelines Minimum of 10 contact hours required. Multiple activities may be used to meet the hour requirement for the criterion. Learning must have occurred in the past 5 years.

Please identify the type of independent learning activity in which you participated:☐ Independent reading of recent peer-reviewed, professional articles, or chapters in textbook not

associated with a formal learning course. ☐ Independent review of professional electronic resources (e.g., NIH, CDC, CanChild).☐ AOTA Journal Club Toolkit (reading & discussion time). Must be AOTA member to access the kit.☐ AOTA Critically Appraised Paper (CAP, includes submission to the AOTA Evidence Exchange).

1. Why did you choose this activity?☐ Clinical reference for specific population, program, or individual ☐ Invited peer review of scholarly work or publication (print or online)☐ Preparation for poster or presentation ☐ Preparation for academic lecture☐ Literature review for research project☐ Preparation for serving as a mentor☐ Other, please specify:

2. Bibliography (APA Format) or list and objectives of select item(s) used for independent learning.

3. Date(s) of independent learning

4. Time spent engaged in independent learning. For reading, estimate 8–12 published pages/hour. For journal club, discussion time counts toward 10-hour requirement.

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

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5. Describe the relevance of the independent learning activity to your practice in physical rehabilitation. (average word guideline–200)

6. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

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

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MENTEEBack to Criteria

Criterion 2–Knowledge: EvaluationDemonstrates acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.

Guidelines Must represent a minimum of 10 hours over a minimum of 2 months. Does not include supervisory relationships. Relationship must have occurred in the past 5 years. May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.

1. Dates of mentoring relationship

2. Approximately how many hours did this represent in total?

3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application. List no more than 3.

A)

B)

C)

4.Mentor

Position/Role of Mentor

Workplace of MentorContact Information for Mentor (email or phone number)

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

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5. State why the mentor was selected to help you meet the goals identified above relative to the criterion. (average word guideline–50)

6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice specific to your ability to “demonstrate acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.” (average word guideline–200)

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

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PUBLICATION – REVIEWED BY EXPERT(S)Back to Criteria

Criterion 2–Knowledge: EvaluationDemonstrates acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.

Guidelines Examples of peer-reviewed publication include journals such as AJOT or OTJR. May include a chapter in an occupational therapy or related professional textbook, if chapter has

gone through peer review (a process in which subject matter experts, using a formal system and defined guidelines, provide content guidance to an author and recommend publication, revision, or rejection of a work).

1. Submit APA reference for the publication. For in-press publication, also include a verification letter or e-mail identifying applicant and anticipated date of publication.

2. If applicant is not identified as first or second author, please describe your contribution/involvement in the development of the publication. (average word guideline–200)

3. Provide a reflection indicating why this publication was chosen to represent “acquisition of current knowledge of relevant evidence specific to evaluation in physical rehabilitation.” (average word guideline–200)

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

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AOTA CERTIFICATION APPLICATION REVIEWERBack to Criteria

Criterion 3–Knowledge: InterventionDemonstrates acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.

Guidelines Complete required training for reviewers at the time of the review period, or once every 2

application cycles if reviewing more than once per year. Serve as a reviewer for 3 AOTA Board Certification applications in physical rehabilitation in the

last 5 years.

1. Please verify activity information:

Date(s) of reviewer training

Date(s) of application review

Total number of applications reviewed

2. Describe how the knowledge acquired from this activity helped you demonstrate “acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your outcomes? (average word guideline–350)

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

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EXPERT WITNESSBack to Criteria

Criterion 3–Knowledge: InterventionDemonstrates acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.

Guidelines Serving as an expert witness in a civil or criminal legal case court or in arbitration. Providing expert testimony in official hearings at the local, state, or national level.

1. Describe the expertise which you were able to share relevant to physical rehabilitation. (average word guideline–200)

2. Describe how the knowledge acquired from this activity helped you “demonstrate acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

3. Submit verification of activity as a separate attachment. May include any 1 of the following: Transcript of the testimony. Notice of deposition. Letter from the attorney.

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

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FORMAL LEARNINGBack to Criteria

Criterion 3–Knowledge: InterventionDemonstrates acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.

Guidelines Minimum of 10 contact hours required. Multiple activities may be used to meet the hour requirement for the criterion. Learning must have occurred in the past 5 years.

Please identify the type of activity in which you participated:☐ AOTA CE: Participation in CE course from AOTA. Does not include courses from AOTA Approved

Providers. Completion of course will be verified by AOTA. Submission of additional documentation beyond this form not required.

☐ Non-AOTA CE: Attending workshops, seminars, lectures, or professional conferences with formal established objectives.

☐ Participation in post-professional academic coursework. Attach unofficial transcript.

1. Activity information.

Activity Title

Provider/Instructor

Activity Date(s)

No. of Contact Hours

2. Activity Learning Objectives. List up to 5.

A)

B)

C)

D)

E)

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

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3. Describe the relevance of the activity to your practice in physical rehabilitation. (average word guideline–200)

4. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

5. Submit documentation that verifies completion of the activity, such as certificate of completion or unofficial transcript. Not required for AOTA courses.

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

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INDEPENDENT LEARNINGBack to Criteria

Criterion 3–Knowledge: InterventionDemonstrates acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.

Guidelines Minimum of 10 contact hours required. Multiple activities may be used to meet the hour requirement for the criterion. Learning must have occurred in the past 5 years.

Please identify the type of independent learning activity in which you participated:☐ Independent reading of recent peer-reviewed, professional articles, or chapters in textbook not

associated with a formal learning course. ☐ Independent review of professional electronic resources (e.g., NIH, CDC, CanChild).☐ AOTA Journal Club Toolkit (reading & discussion time). Must be AOTA member to access the kit.☐ AOTA Critically Appraised Paper (CAP, includes submission to the AOTA Evidence Exchange).

1. Why did you choose this activity?☐ Clinical reference for specific population, program, or individual ☐ Invited peer review of scholarly work or publication (print or online)☐ Preparation for poster or presentation ☐ Preparation for academic lecture☐ Literature review for research project☐ Preparation for serving as a mentor☐ Other, please specify:

2. Bibliography (APA Format) or list and objectives of select item(s) used for independent learning.

3. Date(s) of independent learning

4. Time spent engaged in independent learning. For reading, estimate 8–12 published pages/hour. For journal club, discussion time counts toward 10-hour requirement.

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

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5. Describe the relevance of the independent learning activity to your practice in physical rehabilitation. (average word guideline–200)

6. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

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

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MENTEEBack to Criteria

Criterion 3–Knowledge: InterventionDemonstrates acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.

Guidelines Must represent a minimum of 10 hours over a minimum of 2 months. Does not include supervisory relationships. Relationship must have occurred in the past 5 years. May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.

1. Dates of mentoring relationship

2. Approximately how many hours did this represent in total?

3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application. List no more than 3.

A)

B)

C)

4.Mentor

Position/Role of Mentor

Workplace of MentorContact Information for Mentor (email or phone number)

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

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5. State why the mentor was selected to help you meet the goals identified above relative to the criterion. (average word guideline–50)

6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice specific to your ability to “demonstrate acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.” (average word guideline–200)

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

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PUBLICATION – REVIEWED BY EXPERT(S)Back to Criteria

Criterion 3–Knowledge: InterventionDemonstrates acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.

Guidelines Examples of publication reviewed by experts include journals such as AJOT or OTJR. May include a chapter in an occupational therapy or related professional textbook, if chapter has

gone through peer review (a process in which subject matter experts, using a formal system and defined guidelines, provide content guidance to an author and recommend publication, revision, or rejection of a work).

1. Submit APA reference for the publication. For in-press publication, also include a verification letter or e-mail identifying applicant and anticipated date of publication.

2. If applicant is not identified as first or second author, please describe your contribution/involvement in the development of the publication. (average word guideline–200)

3. Provide a reflection indicating why this publication was chosen to represent “demonstrates acquisition of current knowledge of relevant evidence specific to intervention in physical rehabilitation.” (average word guideline–200)

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AOTA CERTIFICATION APPLICATION REVIEWERBack to Criteria

Criterion 4–Knowledge: SystemsDemonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.

Guidelines Complete required training for reviewers at the time of the review period, or once every 2

application cycles if reviewing more than once per year. Serve as a reviewer for 3 AOTA Board Certification applications in physical rehabilitation in the

last 5 years.

1. Please verify activity information:

Date(s) of reviewer training

Date(s) of application review

Total number of applications reviewed

2. Describe how the knowledge acquired from this activity helped you “demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your outcomes? (average word guideline–350)

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EXPERT WITNESSBack to Criteria

Criterion 4–Knowledge: SystemsDemonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.

Guidelines Serving as an expert witness in a civil or criminal legal case court or in arbitration. Providing expert testimony in official hearings at the local, state, or national level.

1. Describe the expertise which you were able to share relevant to physical rehabilitation. (average word guideline–200)

2. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

3. Submit verification of activity as a separate attachment. May include any 1 of the following: Transcript of the testimony. Notice of deposition. Letter from the attorney.

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FORMAL LEARNINGBack to Criteria

Criterion 4–Knowledge: SystemsDemonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.

Guidelines Minimum of 3 contact hours required. Multiple activities may be used to meet the hour requirement for the criterion. Learning must have occurred in the past 5 years.

Please identify the type of activity in which you participated:☐ AOTA CE: Participation in CE course from AOTA. Does not include courses from AOTA Approved

Providers. Completion of course will be verified by AOTA. Submission of additional documentation beyond this form not required.

☐ Non-AOTA CE: Attending workshops, seminars, lectures, or professional conferences with formal established objectives.

☐ Participation in post-professional academic coursework. Attach unofficial transcript.

1. Activity information.

Activity Title

Provider/Instructor

Activity Date(s)

No. of Contact Hours

2. Activity Learning Objectives. List up to 5.

A)

B)

C)

D)

E)

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3. Describe the relevance of the activity to your practice in physical rehabilitation. (average word guideline–200)

4. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

5. Submit documentation that verifies completion of the activity, such as certificate of completion or unofficial transcript. Not required for AOTA courses.

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INDEPENDENT LEARNINGBack to Criteria

Criterion 4–Knowledge: SystemsDemonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.

Guidelines Minimum of 3 contact hours required. Multiple activities may be used to meet the hour requirement for the criterion. Learning must have occurred in the past 5 years.

Please identify the type of independent learning activity in which you participated:☐ Independent reading of recent peer-reviewed, professional articles, or chapters in textbook not

associated with a formal learning course. ☐ Independent review of professional electronic resources (e.g., NIH, CDC, CanChild).☐ AOTA Journal Club Toolkit (reading & discussion time). Must be AOTA member to access the kit.☐ AOTA Critically Appraised Paper (CAP, includes submission to the AOTA Evidence Exchange).

1. Why did you choose this activity?☐ Clinical reference for specific population, program, or individual ☐ Invited peer review of scholarly work or publication (print or online)☐ Preparation for poster or presentation ☐ Preparation for academic lecture☐ Literature review for research project☐ Preparation for serving as a mentor☐ Other, please specify:

2. Bibliography (APA Format) or list and objectives of select item(s) used for independent learning.

3. Date(s) of independent learning

4. Time spent engaged in independent learning. For reading, estimate 8–12 published pages/hour. For journal club, discussion time counts toward 3-hour requirement.

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5. Describe the relevance of the independent learning activity to your practice in physical rehabilitation. (average word guideline–200)

6. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200)

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MENTEEBack to Criteria

Criterion 4–Knowledge: SystemsDemonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.

Guidelines Must represent a minimum of 10 hours over a minimum of 2 months. Does not include supervisory relationships. Relationship must have occurred in the past 5 years. May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.

1. Dates of mentoring relationship

2. Approximately how many hours did this represent in total?

3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application. List no more than 3.

A)

B)

C)

4.Mentor

Position/Role of Mentor

Workplace of MentorContact Information for Mentor (email or phone number)

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5. State why the mentor was selected to help you meet the goals identified above relative to the criterion. (average word guideline–50)

6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice specific to your ability to “demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.” (average word guideline–200)

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PUBLICATION – REVIEWED BY EXPERT(S)Back to Criteria

Criterion 4–Knowledge: SystemsDemonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.

Guidelines Examples of publication reviewed by experts include journals such as AJOT or OTJR. May include a chapter in an occupational therapy or related professional textbook, if chapter has

gone through peer review (a process in which subject matter experts, using a formal system and defined guidelines, provide content guidance to an author and recommend publication, revision, or rejection of a work).

1. Submit APA reference for the publication. For in-press publication, also include a verification letter or e-mail identifying applicant and anticipated date of publication.

2. If applicant is not identified as first or second author, please describe your contribution/involvement in the development of the publication. (average word guideline–200)

3. Provide a reflection indicating why this publication was chosen to represent “demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to physical rehabilitation.” (average word guideline–200)

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

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ANALYSIS OF RECORDING OR OBSERVATIONBack to Criteria

Criterion 5—Evaluation: Uses Relevant EvidenceUses relevant physical rehabilitation evidence to ensure that an occupational profile with the client (person, organization, population) is established and facilitates the assessment of the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.

Guidelines Submission of actual recording is not required for application; however, appropriate permissions

should be obtained by applicant whenever engaging a client in a recorded session.

1.Age of Client

Client Diagnosis(es)

Setting for Evaluation

Date of Recording

2. Provide a brief summary of the recording contents and how it demonstrates your ability to “use relevant physical rehabilitation evidence to ensure that an occupational profile with the client (person, organization, population) is established and facilitate the assessment of the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.” (average word guideline–200)

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3. After reviewing this recording, describe the insights you gained, and reflect on how the analysis experience validated or supported change in your practice related to evaluation. (average word guideline–400)

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CASE STUDYBack to Criteria

Criterion 5—Evaluation: Uses Relevant EvidenceUses relevant physical rehabilitation evidence to ensure that an occupational profile with the client (person, organization, population) is established and facilitates the assessment of the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.

Guidelines Client-based case study should not include any form of standard client documentation (e.g.,

evaluation summary, discharge plan) or identification of client name(s) or facility information.

1. Date(s) case study represents

2. Describe the client, client factors, and case contexts for the identified case. The context of the case should be adequately communicated so that relevance and merit of the case to the criterion is easily determined. (average word guideline–500)

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3. Articulate how this case demonstrates how you “use relevant physical rehabilitation evidence to ensure that an occupational profile with the client (person, organization, population) is established and facilitate the assessment of the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.” (average word guideline–500)

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FORMAL SPECIALIZED CONSULTATION FOR EVALUATIONBack to Criteria

Criterion 5—Evaluation: Uses Relevant EvidenceUses relevant physical rehabilitation evidence to ensure that an occupational profile with the client (person, organization, population) is established and facilitates the assessment of the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.

Guidelines This should not be confused with consultation that is part of the ongoing services provided in your

routine job duties. It is a request to address a particular issue at a particular site, either external or internal.

Consultation may include (but is not limited to) developing or evaluating a program or service, developing a strategy for long-term planning, establishing outcomes measures, incorporating national guidelines into internal policies and procedures, assessing and addressing staff educational needs, assessing and addressing resource needs, and validating program or service delivery with current evidence.

Applicant must have had a minimum of 10 hours working with the site.

1.Entity for Which Consultation Was CompletedDate(s) of ConsultationNo. of Hours Completed During Consultation

2. Objectives for consultation. Objectives must have been met by time of application. Please list no more than 3.A)

B)

C)

3. Summarize the consultation results. (average word guideline–200)

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4. Summarize how this professional development activity influenced your ability to “use relevant physical rehabilitation evidence to ensure that an occupational profile with the client (person, organization, population) is established and facilitate the assessment of the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.” (average word guideline–400)

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PROGRAM DEVELOPMENTBack to Criteria

Criterion 5—Evaluation: Uses Relevant EvidenceUses relevant physical rehabilitation evidence to ensure that an occupational profile with the client (person, organization, population) is established and facilitates the assessment of the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.

Guidelines Program development refers to the creation of a new program or development of an evolving

program.

1. Dates of program development

2. Briefly describe the program purpose, services offered, and clients served. (average word guideline–250)

3. Describe how this program development activity, including description of resources used, demonstrates your ability to “use relevant physical rehabilitation evidence to ensure that an occupational profile with the client (person, organization, population) is established and facilitate the assessment of the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.” (average word guideline–500)

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RESEARCHBack to Criteria

Criterion 5—Evaluation: Uses Relevant EvidenceUses relevant physical rehabilitation evidence to ensure that an occupational profile with the client (person, organization, population) is established and facilitates the assessment of the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.

What type of research was conducted? Please choose 1. ☐ Scientific inquiry–Qualitative, quantitative, or mixed-methods approach. ☐ Methodological research/instrument development–Scientific inquiry to establish psychometric

properties of (1) a new tool, (2) an existing tool with a new population, or (3) an existing tool translated to a new language.

☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing literature to answer a focused question.

1. Title of research conducted

2. Mechanism of dissemination:☐ Publication ☐ Evidence-Based Practice☐ Peer-reviewed presentation ☐ Project Web site ☐ Grant funding ☐ Dissertation/thesis☐ Critically Appraised Topic (CAT, e.g., AOTA)

Citation:

3. Role of applicant in the research. (average word guideline–25)

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4. Purpose and rationale of the research. (average word guideline–250)

5. Describe how this research demonstrates your ability to “use relevant physical rehabilitation evidence to ensure that an occupational profile with the client (person, organization, population) is established and facilitate the assessment of the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.” (average word guideline–400)

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CASE STUDYBack to Criteria

Criterion 6—Evaluation: Prioritizes NeedsEnsures prioritization of needs related to the client, context, and performance through the synthesis and interpretation of assessment data and clinical observations (or supervision of the same) in physical rehabilitation.

Guidelines Client-based case study should not include any form of standard client documentation (e.g.,

evaluation summary, discharge plan) or identification of client name(s) or facility information.

1. Date(s) case study represents

2. Describe the client, client factors, and case contexts for the identified case. The context of the case should be adequately communicated so that relevance and merit of the case to the criterion is easily determined. (average word guideline–500)

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3. Articulate how this case demonstrates how you “ensure prioritization of needs related to the client, context, and performance through the synthesis and interpretation of assessment data and clinical observations (or supervision of the same) in physical rehabilitation.” (average word guideline–500)

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FORMAL SPECIALIZED CONSULTATION FOR EVALUATIONBack to Criteria

Criterion 6—Evaluation: Prioritizes NeedsEnsures prioritization of needs related to the client, context, and performance through the synthesis and interpretation of assessment data and clinical observations (or supervision of the same) in physical rehabilitation.

Guidelines This should not be confused with consultation that is part of the ongoing services provided in your

routine job duties. It is a request to address a particular issue at a particular site, either external or internal.

Consultation may include (but is not limited to) developing or evaluating a program or service, developing a strategy for long-term planning, establishing outcomes measures, incorporating national guidelines into internal policies and procedures, assessing and addressing staff educational needs, assessing and addressing resource needs, and validating program or service delivery with current evidence.

Applicant must have had a minimum of 10 hours working with the site.

1.Entity for Which Consultation Was CompletedDate(s) of ConsultationNo. of Hours Completed During Consultation

2. Objectives for consultation. Objectives must have been met by time of application. Please list no more than 3.A)

B)

C)

3. Summarize the consultation results. (average word guideline–200)

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4. Summarize how this professional development activity influenced your ability to “ensure prioritization of needs related to the client, context, and performance through the synthesis and interpretation of assessment data and clinical observations (or supervision of the same) in physical rehabilitation.” (average word guideline–400)

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PROGRAM DEVELOPMENTBack to Criteria

Criterion 6—Evaluation: Prioritizes NeedsEnsures prioritization of needs related to the client, context, and performance through the synthesis and interpretation of assessment data and clinical observations (or supervision of the same) in physical rehabilitation.

Guidelines Program development refers to the creation of a new program or development of an evolving

program.

1. Dates of program development

2. Briefly describe the program purpose, services offered, and clients served. (average word guideline–250)

3. Describe how this program development activity, including description of resources used, demonstrates your ability to “ensure prioritization of needs related to the client, context, and performance through the synthesis and interpretation of assessment data and clinical observations (or supervision of the same) in physical rehabilitation.” (average word guideline–500)

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RESEARCHBack to Criteria

Criterion 6—Evaluation: Prioritizes NeedsEnsures prioritization of needs related to the client, context, and performance through the synthesis and interpretation of assessment data and clinical observations (or supervision of the same) in physical rehabilitation.

What type of research was conducted? Please choose 1. ☐ Scientific inquiry–Qualitative, quantitative, or mixed-methods approach. ☐ Methodological research/instrument development–Scientific inquiry to establish psychometric

properties of (1) a new tool, (2) an existing tool with a new population, or (3) an existing tool translated to a new language.

☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing literature to answer a focused question.

1. Title of research conducted

2. Mechanism of dissemination:☐ Publication ☐ Evidence-Based Practice☐ Peer-reviewed presentation ☐ Project Web site ☐ Grant funding ☐ Dissertation/thesis☐ Critically Appraised Topic (CAT, e.g., AOTA)

Citation:

3. Role of applicant in the research. (average word guideline–25)

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4. Purpose and rationale of the research. (average word guideline–250)

5. Describe how this research demonstrates your ability to “ensure prioritization of needs related to the client, context, and performance through the synthesis and interpretation of assessment data and clinical observations (or supervision of the same) in physical rehabilitation.” (average word guideline–400)

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ANALYSIS OF RECORDING OR OBSERVATIONBack to Criteria

Criterion 7—Intervention: Design & ImplementationEnsures the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

Guidelines Submission of actual recording is not required for application; however, appropriate permissions

should be obtained by applicant whenever engaging a client in a recorded session. Observation should be consultative or instructive in nature and a minimum of 1 hour. It may occur

over multiple sessions.

1.Age of Client

Client Diagnosis(es)

Setting for EvaluationDate of Recording or Observation

2. Provide a brief summary of the recording contents or observation and how it demonstrates your ability to “ensure the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average word guideline–200)

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3. After reviewing this recording or observation, describe the insights you gained, and reflect on how the analysis experience validated or supported change in your practice related to intervention – design and implementation. (average word guideline–400)

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CASE STUDY, CLIENT-BASEDBack to Criteria

Criterion 7—Intervention: Design & ImplementationEnsures the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

Guidelines Client-based case study should not include any form of standard client documentation (e.g.,

evaluation summary, discharge plan) or identification of client name(s) or facility information.

1. Date(s) case study represents

2. Describe the client, client factors, and case contexts for the identified case. The context of the case should be adequately communicated so that relevance and merit of the case to the criterion is easily determined. (average word guideline–500)

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3. Articulate how this case demonstrates how you “ensure the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average word guideline–500)

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CASE STUDY, INSTRUCTIONALBack to Criteria

Criterion 7—Intervention: Design & ImplementationEnsures the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

Guidelines Instructional case study refers to teaching that was provided to other practitioners that will be

delivering interventions in physical rehabilitation. It should not include any form of standard client documentation (e.g., evaluation summary, discharge plan) or identification of client name(s) or facility information.

1. Date(s) case study represents

2. Describe the audience and context for the identified case. The context of the case should be adequately communicated so that relevance and merit of the case to the criterion is easily determined. (average word guideline–500)

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3. Articulate how this case demonstrates how you “ensure the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average word guideline–350)

4. How was learning of the audience to whom you were instructing measured? (average word guideline–150)

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FORMAL SPECIALIZED CONSULTATION FOR INTERVENTIONBack to Criteria

Criterion 7—Intervention: Design & ImplementationEnsures the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

Guidelines This should not be confused with consultation that is part of the ongoing services provided in your

routine job duties. It is a request to address a particular issue at a particular site, either external or internal.

Consultation may include (but is not limited to) developing or evaluating a program or service, developing a strategy for long-term planning, establishing outcomes measures, incorporating national guidelines into internal policies and procedures, assessing and addressing staff educational needs, assessing and addressing resource needs, and validating program or service delivery with current evidence.

Applicant must have had a minimum of 10 hours working with the site.

1.Entity for Which Consultation Was CompletedDate(s) of ConsultationNo. of Hours Completed During Consultation

2. Objectives for consultation. Objectives must have been met by time of application. Please list no more than 3.A)

B)

C)

3. Summarize the consultation results. (average word guideline–200)

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4. Summarize how this professional development activity influenced your ability to “ensure the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average word guideline–400)

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MENTEEBack to Criteria

Criterion 7—Intervention: Design & ImplementationEnsures the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

Guidelines Must represent a minimum of 10 hours over a minimum of 2 months. Does not include supervisory relationships. Relationship must have occurred in the past 5 years. May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.

1. Dates of mentoring relationship

2. Approximately how many hours did this represent in total?

3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application. List no more than 3.

A)

B)

C)

4.Mentor

Position/Role of Mentor

Workplace of MentorContact Information for Mentor (email or phone number)

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5. State why the mentor was selected to help you meet the goals identified above relative to the criterion. (average word guideline–50)

6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice specific to your ability to “ensure the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average word guideline–200)

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PROGRAM DEVELOPMENTBack to Criteria

Criterion 7—Intervention: Design & ImplementationEnsures the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

Guidelines Program development refers to the creation of a new program or development of an evolving

program.

1. Dates of program development

2. Briefly describe the program purpose, services offered, and clients served. (average word guideline–250)

3. Describe how this program development activity, including description of resources used, demonstrates your ability to “ensure the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average word guideline–500)

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RESEARCHBack to Criteria

Criterion 7—Intervention: Design & ImplementationEnsures the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

What type of research was conducted? Please choose 1. ☐ Scientific inquiry–Qualitative, quantitative, or mixed-methods approach. ☐ Methodological research/instrument development–Scientific inquiry to establish psychometric

properties of (1) a new tool, (2) an existing tool with a new population, or (3) an existing tool translated to a new language.

☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing literature to answer a focused question.

1. Title of research conducted

2. Mechanism of dissemination:☐ Publication ☐ Evidence-Based Practice☐ Peer-reviewed presentation ☐ Project Web site ☐ Grant funding ☐ Dissertation/thesis☐ Critically Appraised Topic (CAT, e.g., AOTA)

Citation:

3. Role of applicant in the research. (average word guideline–25)

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4. Purpose and rationale of the research. (average word guideline–250)

5. Describe how this research demonstrates your ability to “ensure the design and implementation of physical rehabilitation interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average word guideline–400)

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ANALYSIS OF RECORDING OR OBSERVATIONBack to Criteria

Criterion 8—Intervention: Wellness & PreventionProvides or facilitates physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

Guidelines Submission of actual recording is not required for application; however, appropriate permissions

should be obtained by applicant whenever engaging a client in a recorded session. Observation should be consultative or instructive in nature and a minimum of 1 hour. It may occur

over multiple sessions.

1.Age of Client

Client Diagnosis(es)

Setting for EvaluationDate of Recording or Observation

2. Provide a brief summary of the recording contents or observation and how it demonstrates your ability to “provide or facilitate physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–200)

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3. After reviewing this recording or observation, describe the insights you gained, and reflect on how the analysis experience validated or supported change in your practice related to intervention – wellness and prevention. (average word guideline–400)

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CASE STUDY, CLIENT-BASEDBack to Criteria

Criterion 8—Intervention: Wellness & PreventionProvides or facilitates physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

Guidelines Client-based case study should not include any form of standard client documentation (e.g.,

evaluation summary, discharge plan) or identification of client name(s) or facility information.

1. Date(s) case study represents

2. Describe the client, client factors, and case contexts for the identified case. The context of the case should be adequately communicated so that relevance and merit of the case to the criterion is easily determined. (average word guideline–500)

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3. Articulate how this case demonstrates how you “provide or facilitate physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–500)

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CASE STUDY, INSTRUCTIONALBack to Criteria

Criterion 8—Intervention: Wellness & PreventionProvides or facilitates physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

Guidelines Instructional case study refers to teaching that was provided to other practitioners that will be

delivering interventions in physical rehabilitation. It should not include any form of standard client documentation (e.g., evaluation summary, discharge plan) or identification of client name(s) or facility information.

1. Date(s) case study represents

2. Describe the audience and context for the identified case. The context of the case should be adequately communicated so that relevance and merit of the case to the criterion is easily determined. (average word guideline–500)

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3. Articulate how this case demonstrates how you “provide or facilitate physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–350)

4. How was learning of the audience to whom you were instructing measured? (average word guideline–150)

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FORMAL SPECIALIZED CONSULTATION FOR INTERVENTIONBack to Criteria

Criterion 8—Intervention: Wellness & PreventionProvides or facilitates physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

Guidelines This should not be confused with consultation that is part of the ongoing services provided in your

routine job duties. It is a request to address a particular issue at a particular site, either external or internal.

Consultation may include (but is not limited to) developing or evaluating a program or service, developing a strategy for long-term planning, establishing outcomes measures, incorporating national guidelines into internal policies and procedures, assessing and addressing staff educational needs, assessing and addressing resource needs, and validating program or service delivery with current evidence.

Applicant must have had a minimum of 10 hours working with the site.

1.Entity for Which Consultation Was CompletedDate(s) of ConsultationNo. of Hours Completed During Consultation

2. Objectives for consultation. Objectives must have been met by time of application. Please list no more than 3.D)

E)

F)

3. Summarize the consultation results. (average word guideline–200)

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4. Summarize how this professional development activity influenced your ability to “provide or facilitate physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–400)

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MENTEEBack to Criteria

Criterion 8—Intervention: Wellness & PreventionProvides or facilitates physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

Guidelines Must represent a minimum of 10 hours over a minimum of 2 months. Does not include supervisory relationships. Relationship must have occurred in the past 5 years. May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.

1. Dates of mentoring relationship

2. Approximately how many hours did this represent in total?

3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application. List no more than 3.

D)

E)

F)

4.Mentor

Position/Role of Mentor

Workplace of MentorContact Information for Mentor (email or phone number)

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5. State why the mentor was selected to help you meet the goals identified above relative to the criterion. (average word guideline–50)

6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice specific to your ability to “provide or facilitate physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–200)

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PROGRAM DEVELOPMENTBack to Criteria

Criterion 8—Intervention: Wellness & PreventionProvides or facilitates physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

Guidelines Program development refers to the creation of a new program or development of an evolving

program.

1. Dates of program development

2. Briefly describe the program purpose, services offered, and clients served. (average word guideline–250)

3. Describe how this program development activity, including description of resources used, demonstrates your ability to “provide or facilitate physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–500)

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RESEARCHBack to Criteria

Criterion 8—Intervention: Wellness & PreventionProvides or facilitates physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

What type of research was conducted? Please choose 1. ☐ Scientific inquiry–Qualitative, quantitative, or mixed-methods approach. ☐ Methodological research/instrument development–Scientific inquiry to establish psychometric

properties of (1) a new tool, (2) an existing tool with a new population, or (3) an existing tool translated to a new language.

☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing literature to answer a focused question.

1. Title of research conducted

2. Mechanism of dissemination:☐ Publication ☐ Evidence-Based Practice☐ Peer-reviewed presentation ☐ Project Web site ☐ Grant funding ☐ Dissertation/thesis☐ Critically Appraised Topic (CAT, e.g., AOTA)

Citation:

3. Role of applicant in the research. (average word guideline–25)

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4. Purpose and rationale of the research. (average word guideline–250)

5. Describe how this research demonstrates your ability to “provide or facilitate physical rehabilitation interventions that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–400)

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FORMAL SPECIALIZED CONSULTATION FOR OUTCOMESBack to Criteria

Criterion 9—OutcomesEnsures that services that are delivered, either for caseload or programs, are validated and that changes are made as appropriate to maximize outcomes related to physical rehabilitation.

Guidelines This should not be confused with consultation that is part of the ongoing services provided in your

routine job duties but is a request to address a particular issue at a particular site, either external or internal.

Consultation may include (but is not limited to) developing or evaluating a program or service, developing a strategy for long-term planning, establishing outcomes measures, incorporating national guidelines into internal policies and procedures, assessing and addressing staff educational needs, assessing and addressing resource needs, and validating program or service delivery with current evidence.

Applicant must have had a minimum of 10 hours working with the site.

1.Entity for Which Consultation Was CompletedDate(s) of ConsultationNo. of Hours Completed During Consultation

2. Objectives for consultation. Objectives must have been met by time of application. Please list no more than 3.A)

B)

C)

3. Summarize the consultation results. (average word guideline–200)

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4. Summarize how this professional development activity influenced your ability to “ensure that services that are delivered, either for caseload or programs, are validated and that changes are made as appropriate to maximize outcomes related to physical rehabilitation.” (average word guideline–400)

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PROGRAM or SERVICE EVALUATION & RECOMMENDATIONBack to Criteria

Criterion 9—OutcomesEnsures that services that are delivered, either for caseload or programs, are validated and that changes are made as appropriate to maximize outcomes related to physical rehabilitation.

Guidelines Refers to evaluation of an activity implemented in a program, department, facility, or organization. Should not include any form of standard client documentation (e.g., evaluation summary, discharge

plan) or identification of client name(s) or facility information.

1.Type of Program or Service Being Evaluated

Date(s) of Evaluation

2. Describe the caseload or program being evaluated. The context should be adequately communicated so that relevance and merit to the criterion is easily determined. (average word guideline–300)

3. Identify methods or tools used for the program or service evaluation. (average word guideline–200)

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4. Summarize evaluation findings. (average word guideline–200)

5. What actions were taken in response to the findings? (average word guideline–300)

6. Summarize how this program evaluation demonstrates your ability to “ensure that services that are delivered, either for caseload or programs, are validated and that changes are made as appropriate to maximize outcomes related to physical rehabilitation.” (average word guideline–300)

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RESEARCHBack to Criteria

Criterion 9—OutcomesEnsures that services that are delivered, either for caseload or programs, are validated and that changes are made as appropriate to maximize outcomes related to physical rehabilitation.

What type of research was conducted? Please choose 1. ☐ Scientific inquiry–Qualitative, quantitative, or mixed-methods approach. ☐ Methodological research/instrument development–Scientific inquiry to establish psychometric

properties of (1) a new tool, (2) an existing tool with a new population, or (3) an existing tool translated to a new language.

☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing literature to answer a focused question.

1. Title of research conducted

2. Mechanism of dissemination:☐ Publication ☐ Evidence-Based Practice☐ Peer-reviewed presentation ☐ Project Web site ☐ Grant funding ☐ Dissertation/thesis☐ Critically Appraised Topic (CAT, e.g., AOTA)

Citation:

3. Role of applicant in the research. (average word guideline–25)

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4. Purpose and rationale of the research. (average word guideline–250)

5. Describe how this research demonstrates your ability to “ensure that services that are delivered, either for caseload or programs, are validated and that changes are made as appropriate to maximize outcomes related to physical rehabilitation.” (average word guideline–400)

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CASE STUDY, HOLISTIC PRACTICEBack to Criteria

Criterion 10— Holistic PracticeEnsures that client’s needs, including physical, social, and emotional well-being, are addressed holistically to maximize occupational performance in physical rehabilitation.

Guidelines Client-based case study should not include any form of standard client documentation (e.g.,

evaluation summary, discharge plan) or identification of client name(s) or facility information. Client refers to a person, organization, or population.

1. Identify the primary reason for referral:☐ Physical☐ Social☐ Emotional

2. Date(s) case study represents.

3. Describe the client, client factors, and case contexts for the identified case. (average word guideline–300)

4. Describe other client needs (physical, social, emotional) you identified over the course of involvement and how you addressed these needs. (average word guideline–100)

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5. Articulate how this case demonstrates your ability to “ensure that client’s needs, including physical, social, and emotional well-being, are addressed holistically to maximize occupational performance in physical rehabilitation.” (average word guideline–500)

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PROGRAM DEVELOPMENTBack to Criteria

Criterion 10— Holistic PracticeEnsures that client’s needs, including physical, social, and emotional well-being, are addressed holistically to maximize occupational performance in physical rehabilitation.

Guidelines Program development refers to the creation of a new program or development of an evolving

program.

1. Dates of program development

2. Briefly describe the program purpose, services offered, and clients served. (average word guideline–250)

3. Describe how this program development activity, including description of resources used, demonstrates your ability to “ensure that client’s needs, including physical, social, and emotional well-being, are addressed holistically to maximize occupational performance in physical rehabilitation.” (average word guideline–500)

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PROGRAM OR SERVICE EVALUATION & RECCOMMENDATIONBack to Criteria

Criterion 10— Holistic PracticeEnsures that client’s needs, including physical, social, and emotional well-being, are addressed holistically to maximize occupational performance in physical rehabilitation.

Guidelines Refers to evaluation of an activity implemented in a program, department, facility, or organization. Should not include any form of standard client documentation (e.g., evaluation summary, discharge

plan) or identification of client name(s) or facility information.

1.Type of Program or Service Being Evaluated

Date(s) of Evaluation

2. Describe the caseload or program being evaluated. The context should be adequately communicated so that relevance and merit to the criterion is easily determined. (average word guideline–300)

3. Identify methods or tools used for the program/service evaluation. (average word guideline–200)

4. Summarize evaluation findings. (average word guideline–200)

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5. What actions were taken in response to the findings? (average word guideline–300)

6. Summarize how this program evaluation demonstrates your ability to “ensure that client’s needs, including physical, social, and emotional well-being, are addressed holistically to maximize occupational performance in physical rehabilitation.” (average word guideline–300)

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ADVOCACY EFFORTSBack to Criteria

Criterion 12— Advocating for ChangeAdvances access to services or influences policies or programs that promote the health and occupational engagement of clients (persons, organizations, populations) in the area of physical rehabilitation.

Guidelines Active involvement in or facilitation of advocacy activities at the local, regional, state, or national

level for the purpose of influencing decision-makers about policy, procedures, services, reimbursement, or occupational justice issues.

Merely serving as a participant does not constitute advocacy efforts. Minimum of 10 hours over at least 2 months.

Type of advocacy activity: (check all that apply)☐ Development and dissemination of advocacy materials (e.g., letters, brochures, Web sites,

podcasts)☐ Lobbying to/education for policy-makers☐ Organizer of community event (e.g., fundraising, health fair)☐ Subject expert in media interview (e.g., radio, television news, newspaper)☐ Presentation to stakeholder☐ Other

1.Description of Activity Target Audience Date(s) No. of Hours

Involved

2. Applicant’s objectives for advocating for change. List no more than 3.A)

B)

C)

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3. Discuss the results, outcomes, or progress toward change affected by this advocacy effort that demonstrates how you “advance access to services or influence policies or programs that promote the health and occupational engagement of clients (persons, organizations, populations) in the area of physical rehabilitation.” (average word guideline–350)

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CASE STUDY, ADVOCACYBack to Criteria

Criterion 12— Advocating for ChangeAdvances access to services or influences policies or programs that promote the health and occupational engagement of clients (persons, organizations, populations) in the area of physical rehabilitation.

Guidelines Efforts toward change that influence access to services, policy, or programs that promote the

health and occupational engagement of clients. This should not be confused with routine job duties associated with expected occupational therapy

service delivery. For example, submitting letters of necessity for equipment would not meet intent.

1. Describe the client (person, organization, population) or program and the context as it applies to an identified need for change. (average word guideline–100)

2. Summarize your efforts to influence change. (average word guideline–200)

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3. Describe the change outcomes or progress toward change as a result of your efforts. (average word guideline–200)

4. Articulate how this case demonstrates your ability to “advance access to services or influence policies or programs that promote the health and occupational engagement of clients (persons, organizations, populations) in the area of physical rehabilitation.” (average word guideline–500)

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VOLUNTEER LEADERSHIPBack to Criteria

Criterion 12— Advocating for ChangeAdvances access to services or influences policies or programs that promote the health and occupational engagement of clients (persons, organizations, populations) in the area of physical rehabilitation.

Guidelines Service with a local, state, national, or international agency or organization that has relevance to

the criterion. Minimum of 25 hours for at least 1 year.

1. Name of organization

2. Dates of service

3. Approximate number of hours of service

4. Identification of the volunteer leadership role served (must be leadership in nature, e.g., officer, chair, committee member, board member)

5. Describe how this leadership activity helped you “advance access to services or influence policies or programs that promote the health and occupational engagement of clients (persons, organizations, populations) in the area of physical rehabilitation.” (average word guideline–400)

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NETWORKING CASE STUDYTable of Contents

Criterion 13– Establishes Networks & ResourcesEstablishes or contributes to the advancement of physical rehabilitation networks and collaborates with team members, referral sources, or stakeholders to support clients’ occupational engagement.

Guidelines The networking case study should reflect an understanding of the system in which you work and an

ability to establish networks and resources outside of your routine work group and referral pathways. The networking case study should not include any form of standard client documentation (e.g.,

evaluation summary, discharge plan).

1. Date(s) case study represents.

2. Identify the issue(s) that interfered with the occupational engagement for one or more clients (person, organization, population). (average word guideline–100)

3. Identify the key networks or resources you established or accessed to address the issue. (average word guideline–100)

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4. Articulate how this case demonstrates your ability to “establish or contribute to the advancement of physical rehabilitation networks and collaborate with team members, referral sources, or stakeholders to support clients’ occupational engagement.” (average word guideline–500)

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Documentation of ServiceBack to Criteria

Criterion/Activity Exchange 13 Service to BASCApplies advanced knowledge to encourage, support, and recognize continued competence and professional development of members in board areas of practice.

Guidelines Service to the BASC in one or more of the following capacities within the last 5 years can be used

in exchange for meeting one criterion:

☐ Served as a reviewer for at least five AOTA Certification applications (initial and/or renewal)☐ Served on the BASC☐ Participated as a Phase I or II Panel Member: _______________________ (indicate which)

1. Please verify relevant activity information:

Date(s) of application review:

Total number of applications reviewed:

Dates as a BASC Member:

Dates as a Phase I or II Panel Member:

2. Submit documentation that verifies completion of activity, such as thank you letters from AOTA. If you are unable to locate verification information, please contact [email protected] a minimum of 2 weeks in advance of the renewal deadline to obtain this information.

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