Continuing Competency Requirement 

Individual Activity Approval Request 

Date: _________________________________

 

Contact Name: _________________________________________________________________________

Phone:__________________________________________________________________________________________

Address: ________________________________________________________________________________________
________________________________________________________________________________________________

Activity Format:  
[ ] Videotaped Presentation [ ] Publications Published [ ] Self-Study
[ ] In-Service Training [ ] Research Project [ ] Instruction/Supervision
[ ] Presentation [ ] Quality Assurance Program [ ] Specialty Examinations 
[ ] College/University [ ] Review of Papers [ ] OT Volunteer

Activity Title: _______________________________________________________________________________________________

Name of SPONSORING organization: ___________________________________________________________________________

List of documentation submitted for Board review.  Please fill in the blanks.  Refer to the Code of Maryland Regulations (COMAR) 10.46.04.05 for guidance on acceptable documentation.

List of documentation submitted for Board review.  Please fill in the blanks.  Refer to the Code of Maryland Regulations (COMAR) 10.46.04.05 for guidance on acceptable documentation. 

For Board Office Use Only
1.  ___________________________________  Application # ________________________
Date Received:  ____________________
Date Reviewed: ____________________

Content:      Congruent with goals:        Y   /   N
                    Appropriate:                     Y   /   N
Resources:    Qualified:                          Y   /   N
                    Appropriate:                     Y   /   N
Activity Approved:                               Y  /   N
Schedule:                                                                                  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.
2.  ___________________________________
3.  ___________________________________ 
4.  ___________________________________ 
Proof of completion must be furnished in order for credit to be applied.  Please indicate the form this documentation is anticipated to take: 
_____________________________________
_____________________________________   _____________________________________
TOTAL HOURS APPROVED:  ____  

________________________________________ Signed, Board Reviewer

Reason Not Approved/Additional Comments: _____________________________________________________________________________________________

__________________________________________________________________________________

[  ]  Does not contribute to maintenance of professional competency or improvement of professional skills in occupational therapy theory and practice.

Courses sponsored by the Maryland Occupational Therapy Association or American Occupational Therapy Association are granted pre-approval and need not be submitted.  Verification of completion must be maintained by each participant.  For all other programs, please submit the requested information to the Board at least 60 days in advance of the activity for pre-approval.