Continuing Competency Requirement Approval Request
Date: _________________________________
Contact Name: _________________________________________________________________________
Phone:__________________________________________________________________________________________
Address:
________________________________________________________________________________________
________________________________________________________________________________________________
Course Title:
_____________________________________________________________________________________
Name of SPONSORING organization: _________________________________________________________
Courses sponsored by the MOTA or AOTA are granted pre-approval and need not be
submitted. A certificate of completion
must be maintained by each participant.
Checklist |
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For Board Office Use Only |
Sponsor/
Licensee |
Board Review |
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Application #_____________________________
Date Received:
____________________
Date Reviewed: ____________________
Content: Congruent with
goals: Y
/ N
Appropriate:
Y / N
Faculty: Qualified:
Y / N
Appropriate:
Y / N
Program Approved:
Y / N
Schedule: Number of days: ________________
Total credit hours: ______________
Instructional hours of less than 1/2 an hour will not be awarded. No
credits will be given for registration, introductions, orientation time,
welcoming speeches, lunch, breaks, etc.
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1. Course description |
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2. Brief biography/resume of presenter |
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3. Hour by hour agenda |
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4. Dates and location of course |
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(A copy of the program brochure with appropriate information can
be substituted for the above.) |
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5. $30 check made payable to the Maryland Board of
Occupational Therapy mailed to Spring Grove Hospital Center, 55 Wade Avenue, Baltimore, MD
21228. (Sponsors
only) |
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The provider of this continuing education course shall furnish a certification of
completion to all participants. The
certification shall include:
A. Name of provider
B. Name of program
C. Name of participant
D. Dates of course
E. Number of approved contact hours
The Board may require verification of presenter's licensure status. Approval by this Board entitles the sponsor to publish
a statement such as, "This
continuing education program has been approved by the Maryland Board of O.T. Practice
for
_____ contact hours: one teaching hour equals one contact hour."
TOTAL HOURS AWARDED:
_______________________________________________ Signed, Board Reviewer
Reason Not Approved/Additional Comments:
_____________________________________________________________________________________________
__________________________________________________________________________________
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