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SCHOOL SYSTEMS SPECIALTY CERTIFICATIONOccupational Therapist

Table of Contents: ACTIVITY EVIDENCE FORMSInstructions:

Please complete 1 form for each criterion. Combine completed forms in a single document (e.g., Word or .PDF) and submit with the completed application to https://www.filesdirect.com/AOTACertification.

Please do not include unused forms.

Criterion 1: Knowledge: Diagnostic Considerations Expert Witness Formal Learning – Minimum 10 contact hours

needed Independent Learning –Minimum 10 contact hours

needed Publication – Peer-Reviewed

Criterion 2: Knowledge: Evaluation Expert Witness Formal Learning –Minimum 10 contact hours



Criterion 3: Knowledge: Intervention Expert Witness Formal Learning –Minimum 10 contact hours



Criterion 4: Knowledge: Regulation & Payers Expert Witness Formal Learning –Minimum 3 contact hours needed Independent Learning –Minimum 3 contact hours


Criterion 5: Evaluation: Performance Skills Client-Based Case Study Mentee (does not include supervisory relationship) Self-Analysis of Video Recording

Criterion 6: Evaluation: Critical Reasoning Critical Reasoning Scenarios (2)

o List of Assessments for CR Scenarios Formal Specialized Consultation for Evaluation Program Development Research

Criterion 7: Intervention: Performance Skills Client-Based Case Study Mentee (does not include supervisory relationship) Self-Analysis of Video Recording

Criterion 8: Intervention: Critical Reasoning Client-Based Case Study Formal Specialized Consultation for Intervention Mentee (does not include supervisory relationship) Program Development Research

Criterion 9: Psychosocial Critical Reasoning Client-Based Case Study Formal Specialized Consultation for Psychosocial Mentee (does not include supervisory relationship) Program Development Research

Criterion 10: Ethical Practice – The 3 ethical practice scenarios are found within the application itself.

Criterion 11: Establishes Networks Formal Specialized Consultation Marketing Activities Presentation Volunteer Leadership

Criterion 12: Advocating for Change Advocacy Efforts Advocacy Case Study Presentation Public Awareness Effort s Volunteer Leadership

© 2015 The American Occupational Therapy Association, Inc. All rights reserved.

https://www.filesdirect.com/AOTACertification

EXPERT WITNESS/TESTIMONYBack to Criteria

Criterion 1–Knowledge: Diagnostic ConsiderationsDemonstrates knowledge of primary and secondary conditions that impact occupational engagement related to school systems.

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 school systems. (average word guideline–200)

2. Describe how the knowledge acquired from this activity “demonstrates knowledge of primary and secondary conditions that impact occupational engagement related to school systems.” 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.


FORMAL LEARNINGBack to Criteria


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 Self-Paced Clinical Course or CE Product from the list of AOTA offerings

approved for this certification. 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)


3. Describe the relevance of the activity to your practice in school systems. (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.


INDEPENDENT LEARNINGBack to Criteria



Please identify the type of independent learning activity in which you participated:☐ Independent reading from AOTA-Approved Independent Learning List in school systems.☐ 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 of select item(s) used for independent learning. List in APA format.

3. Date(s) of independent learning

4. Time spent engaged in independent learning. For reading, estimate 8–12 published pages/hour. Not required for AOTA-identified independent

learning list of resources. For journal club, discussion time counts toward 10-hour requirement.


http://www.aota.org/en/Practice/Researchers/Evidence-Exchange.aspx

http://www.aota.org/en/Practice/Researchers/Journal-Club-Toolkit.aspx

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



PUBLICATION – PEER-REVIEWEDBack to Criteria


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 “knowledge of primary and secondary conditions that impact occupational engagement related to school systems. (average word guideline–200)



Criterion 2—Knowledge: EvaluationDemonstrates knowledge of relevant evidence specific to evaluation in school systems.



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











Activity Title

Provider/Instructor

Activity Date(s)



A)

B)

C)

D)

E)








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



Criterion 3—Knowledge: InterventionDemonstrates knowledge of relevant evidence specific to intervention in school systems.



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











Activity Title

Provider/Instructor

Activity Date(s)



A)

B)

C)

D)

E)








3. Provide a reflection indicating why this publication was chosen to represent “knowledge of relevant evidence specific to intervention in school systems. (average word guideline–200)



Criterion 4—Knowledge: Regulation & PayersDemonstrates knowledge of laws and regulations relevant to school systems, including payer sources.














Activity Title

Provider/Instructor

Activity Date(s)



A)

B)

C)

D)

E)



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




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








3. Provide a reflection indicating why this publication was chosen to represent “knowledge of laws and regulations relevant to school systems, including payer sources.” (average word guideline–200)


CLIENT-BASED CASE STUDYBack to Criteria

Criterion 5—Evaluation: Performance SkillsAdministers standardized assessments specific to school systems, consistently integrating clinical observations throughout the evaluation process.

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)


3. Articulate how this case demonstrates how you “administer standardized assessments specific to school systems, consistently integrating clinical observations throughout the evaluation process.” (average word guideline–500)


MENTORING RELATIONSHIP–MENTEEBack to Criteria


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.

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)


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 how you “administer standardized assessments specific to school systems, consistently integrating clinical observations throughout the evaluation process.” (average word guideline–200)


SELF-ANALYSIS OF VIDEO RECORDINGBack to Criteria


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

permissions should be obtained by applicant whenever engaging a client in a video-taped session.

1.Age of Client

Client Diagnosis(es)

Setting for Evaluation

Date of Video Recording

2. Provide a brief summary of the video contents and how it demonstrates your ability to “administer standardized assessments specific to school systems, consistently integrating clinical observations throughout the evaluation process.” (average word guideline–200)


3. After reviewing this video, 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)


CRITICAL REASONING SCENARIOSBack to Criteria

Criterion 6—Evaluation: Critical ReasoningSynthesizes and interprets assessment data and clinical observations related to the client, context, and performance in school systems.

Guidelines Applicant chooses 2 assessments and completes this 2-part form relative to the application of each

assessment tool with a client. Selected tools can either have been used with the same client or different clients.

Assessment tools may be identified from the list, or applicants may submit an assessment that is not listed.

For each assessment, answer the following questions by reflecting upon a case from your practice. You may choose to use different cases for each assessment tool.

Part IASSESSMENT 1 (Part 1 of 2)1. Name of assessment.

2. Describe the client, client factors, and case contexts that contributed to your selection of the assessment for the identified case.

3. What considerations regarding reliability, validity, relevance, and currency did you consider when selecting this assessment?

4. Describe the assessment results, including those gathered through clinical observation, and what these results told you about the client’s occupational performance.

Continued next page


5. Describe how and why you integrated these results into the client’s intervention plan.

Part II

ASSESSMENT 2 (Part 2 of 2)6. Name of assessment.

7. Describe the client, client factors, and case contexts that contributed to your selection of the assessment for the identified case.

8. What considerations regarding reliability, validity, relevance, and currency did you consider when selecting this assessment?

9. Describe the assessment results, including those gathered through clinical observation, and what these results told you about the client’s occupational performance.

10. Describe how and why you integrated these results into the client’s intervention plan.


CRITICAL REASONING SCENARIO ASESSMENTS– Criterion 6Specialty Certification in School Systems

To complete the scenario activity, applicant may choose 2 assessments from the list below or complete the activity form with one (or two) assessments that are not listed. Examples provided may be with the same client or different clients.

This list was compiled in January 2013. Newer editions of these assessment tools may be available. Applicants would be expected to use the most current edition.

Aspects of Occupational Therapy Domain – Corresponds with the table below.1. Activity Demands - Objects used and their properties, Space demands, Social demands,

Sequencing and timing, Required actions, Required body functions, Required body structures2. Areas of Occupation - Activities of Daily Living, Instrumental Activities of Daily Living, Rest

and Sleep, Education, Work, Play, Leisure, Social Participation3. Client Factors - Values, Beliefs, Spirituality, Body Functions, Body Structures4. Context - Cultural, Personal, Physical, Social, Temporal, Virtual5. Performance Patterns - Habits, Routines, Roles, Rituals6. Performance Skills - Sensory-Perceptual, Motor and Praxis, Emotional Regulation, Cognitive,

Communication and Social Skills

OT DomainAssessments Ages or Grades References 1 2 3 4 5 6

Adaptive Behavior Assessment System-Second Edition (ABAS-II)

Birth-89 years Harrison, P., & Oakland, T. (2003). Adaptive behavior assessment system (2nd ed.). Antonio, TX: Psychological Corporation.

X X

Assessment, Evaluation, and Programming System for Infants and Children-Second Edition (AEPS®)

0-6 years Bricker, D. (Ed). (2002). Assessment, evaluation, and programming system (2nd ed.). Baltimore, MD: Paul H. Brookes.

X

Battelle Developmental Inventory, 2nd Edition (BDI-2™)

0-8 years Newborg, J. (2005). Battelle developmental inventory (2nd ed.). Itasca, IL: Riverside Publishing.

X

Beery-Buktenica Test of Visual-Motor Integration, 6th Edition (VMI)

2-100 years Beery, K., & Beery, N. (2010). The beery-buktenica developmental test of visual motor integration (6th ed). Bloomington, MN: Pearson.

X

Bruininks-Oseretsky Test of Motor Proficiency-2nd Edition (BOT-2)

4-21 years Bruininks, R., & Bruininks, B. (2005). Bruininks-oseretsky test of motor proficiency (2nd ed.). Minneapolis, MN: NCS Pearson.

X



Canadian Occupational Performance Measure 4th Edition (COPM)

8 years-adult Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollock, N. (2005). Canadian occupational performance measure. Ontario, Canada: CAOT Publications.

X

Carolina Curriculum for Preschoolers with Special Needs, Second Edition

2-5 years’ developmental age

Johnson-Martin, N. M., Attermeier, S. M., & Hacker, B. (2004). The Carolina curriculum for preschoolers with special needs (2nd ed.). Baltimore, MD: Paul H. Brookes.

X

Child Occupational Self Assessment (COSA)

7-17 years Keller, J., Kafkes, A., Basu, S., Federico, J., & Kielhofner, G. (2005). Child occupational self assessment. Chicago, IL: MOHO Clearinghouse.

X X X

Children's Assessment of Participation and Enjoyment (CAPE) & Preferences for Activities of Children (PAC)

6-21 years King, G., Law, M., King, S., Hurley, P., Hanna, S., Kertoy, M., Rosenbaum, P., & Young, N. (2004). Children’s assessment of participation and enjoyment and preferences for activities of children. San Antonio, TX: Harcourt Assessment.

X

Children's Assessment of Participation and Enjoyment (CAPE) & Preferences for Activities of Children (PAC)

6-21 years King, G., Law, M., King, S., Hurley, P., Hanna, S., Kertoy, M., Rosenbaum, P., & Young, N. (2004). Children’s assessment of participation and enjoyment and preferences for activities of children. San Antonio, TX: Harcourt Assessment.

X X

Developmental Test of Visual Perception, 2nd Edition (DVPT-2)

4-10 years Hammill, D., Pearson, N., & Voress, J. (1993). Developmental test of visual perception (2nd ed.). Austin, TX: Pro-ed.

X

Developmental Test of Visual Perception-Adolescent and Adult (DTVP-A)

11-74 years Reynold, C., Voress, J., & Pearson, N. (2002). Developmental test of visual perception-adolescent and adult. Austin, TX: Pro-ed.

X

Evaluation Tool of Children’s Handwriting (ETCH)

Grades 1-6 Amundson, S. (1995). Evaluation tool of children’s handwriting.Homer, AK: O.T. Kids.

X

Every Move Counts, Clicks & Chats All ages Korsten, J., Foss, T., & Berry, L. (2007). Every move counts: Clicks and chats. Lee’s Summit, MO: EMC.

X

Gross Motor Function Measure (GMFM-66 and GMFM-88)

Less than 5 years developmentally

Russell, D., Rosenbaum, J., Avery, L., & Lane, M. (2002). Gross motor function measure. Hoboken, NJ: Wiley Blackwell Publishing.

X X



McMaster Handwriting Assessment Protocol -2nd edition

Grades K-6 Pollock, N., Lockhart, J., Blowes, B., Semple, K., Webster, M., Farhat, L., Jacobson, J., Bradley, J., & Brunetti, S. (2009). Handwriting assessment protocol (2nd ed.). Hamilton, Ontario: McMaster University.

X

Miller Function and Participation Scales 2.6-7.11 years Miller, L. (2006). Miller function and participation scales. San Antonio, TX: Harcourt Assessment.

X

Minnesota Handwriting Assessment Grades 1-2 Reisman, J. (1999). Minnesota handwriting assessment. San Antonio, TX: Psychological Corporation.

X

Motor-Free Visual Perception Test-3 (MVPT-3)

4-12 years Colarusso, R., & Hamill, D. (2003). Motor-free visual perception test (3rd ed.). Novato, CA: Academic Therapy Publications.

X

Occupational Self Assessment (OSA) 12+ years Baron, K., Kielhofner, G., Iyenger, A., Goldhammer, V., & Wolenskil, J. (2006). Occupational self assessment. Chicago, IL: MOHO Clearninghouse.

X X X

Occupational Therapy Psychosocial Assessment of Learning, Version 2.0 (OT PAL)

6-12 years Townsend, S., Carey, P., Hollins, N., Helfrich, C., Blondis, M., Hoffman, A., Collins, L., Knudson, J., & Blackwell , A. (1999). Occupational therapy psychosocial assessment of learning: Version 2.0. Chicago, IL: MOHO Clearinghouse.

X X

Peabody Developmental Motor Scales (PDMS-2)

Birth-5 years Folio, M. R., & Fewell, R. R. (2000). Peabody developmental motor scales (2nd ed.). San Antonio, TX: Psychological Corporation.

X

Pediatric Evaluation of Disability Inventory (PEDI)

6 months-7 years developmentally

Haley, S., Coster, W., Ludlow, L., Haltiwanger, J., & Andrellos, P. (1992). Pediatric evaluation of disability inventory. Boston, MA: Trustees of Boston University.

X X

Perceived Efficacy and Goal Setting System (PEGS)

5-10 years Missiuna, C., Pollock, N., & Law, M. (2004). Perceived efficacy and goal setting system. San Antonio, TX: Psychological Corporation.

X X

Print Tool 6 years and up Olsen, J. (2005). The print tool. Cabin John, MD: Handwriting Without Tears.

X



School Assessment of Motor and Process Skills, 2nd edition (School AMPS)

3-12 years Fisher, A. G., Bryze, K., Hume, V. H., & Griswold, L. A. (2005). School AMPS: School version of the assessment of motor and process skills (2nd ed.). Fort Collins, CO: Three Star Press.

X

School Function Assessment (SFA) Grades K-6 Coster, W., Deeney, T., Haltiwanger, J., & Haley, S. (1998). School function assessment. San Antonio, TX: The Psychological Corporation.

X

School Setting Interview Grades K-12 Hemmingsson, H., Egilson, S., Hoffman, O., & Kielfhofner, G. (2005). The school setting interview. Chicago, IL: MOHO Clearinghouse.

X X X

Sensory Processing Measure Grades K-6 Parham, L., Ecker, C. , Kuhaneck, H., Henry, D., & Glennon, T. (2007). Sensory processing measure. Los Angeles, CA: Western Psychological Services.

X

Sensory Processing Measure-Preschool 2-5 years Ecker, C. , Parham, L., Kuhaneck, H., Henry, D., & Glennon, T. (2010). Sensory processing measure-preschool. Los Angeles, CA: Western Psychological Services.

X

Sensory Profile 3-10 years Dunn, W. (1999). Sensory profile. San Antonio, TX: Psychological Corporation.

X

Sensory Profile: Adolescent/Adult 11 years-adult Brown, C., & Dunn, W. (2002). Adolescent/adult sensory profile. San Antonio, TX: Psychological Corporation.

X

Sensory Profile-School Companion 3-11 years Dunn, W. (2006). Sensory profile-school companion. San Antonio, TX: Psychological Corporation.

X

Short Child Occupational Profile (SCOPE) Birth-21 years Bowyer, P., Kramer, J., Ploszaj, A., Ross, M., Schwartz, O., Kielhofner, G., et al. (2008). The short child occupational profile (Version 2.2). Chicago: University of Illinois.

X X X

Supports Intensity Scale 16 years-adult Thompson, J., Bryant, B., Campbell, E., & Craig , E.(2010). Supports intensity scale. Washington DC: American Association on Intellectual and Developmental Disabilities.

X X



Test of Environmental Supportiveness (TOES)

6 months-18 years Skard, G., & Bundy, A. C. (2008). Test of environmental supportiveness. In L. D. Parham & L. S. Fazio (Eds.), Play in occupational therapy for children (2nd ed., pp. 71-93). St Louis, MO: Mosby.

X X

Test of Handwriting Skills-Revised (THS-R) 5-18.11 years Milone, M. (2007). Test of handwriting skills-revised. Novato, CA: Academic Therapy Publications.

X

Test of Playfulness (ToP) (Version 4.0—5/05) 6 months-18 years Skard, G., & Bundy, A. C. (2008). Test of playfulness. In L. D. Parham & L. S. Fazio (Eds.), Play in occupational therapy for children (2nd ed., pp. 71-93). St Louis, MO: Mosby.

X X

Test of Visual Perceptual Skills, 3rd Edition 4-18 years Martin, N. A.. (2006). Test of visual perceptual skills (3rd ed.). Novato, CA: Academic Therapy Publications.

X

Transdisciplinary Play-Based Assessment 2nd Edition

Birth-6 years Linder, T. W. (2008). Trans-disciplinary play-based assessment (2nd ed). Baltimore, MD: Paul H. Brookes.

X

Vineland Adaptive Behavior Scales, 2nd Edition (Vineland-II)

Birth-90 years Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2007). The vineland adaptive behavior scales (2nd ed.). Circle Pines, MN: AGS Publishing.

X

Work Environment Impact Scale (WEIS) Adolescent-young adult in vocational

training

Moore-Corner, R. A., Kielhofner, G., & Olson, L. (1998). Work environment impact scale (Version 2.0). Chicago: University of Illinois.

X

Worker Role Interview (WRI) Adolescent-young adult in vocational

training

Braveman, B., Robson, M., Velozo, C., Kielhofner, G. F., Forsyth, K., & Kerschbaum, J. (2005). Worker role interview (Version 10.0). Chicago: University of Illinois.

X X


FORMAL SPECIALIZED CONSULTATION FOR EVALUATIONBack to Criteria


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/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)


4. Summarize how this professional development activity influenced your ability to “synthesize and interpret assessment data and clinical observations related to the client, context, and performance in school systems.” (average word guideline–400)


PROGRAM DEVELOPMENTBack to Criteria


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 “synthesize and interpret assessment data and clinical observations related to the client, context, and performance in school systems.” (average word guideline–500)


RESEARCHBack to Criteria


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)


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

5. Describe how this research demonstrates your ability to “synthesize and interpret assessment data and clinical observations related to the client, context, and performance in school systems.” (average word guideline–400)



Criterion 7—Intervention: Performance SkillsPerforms interventions that are unique to school systems while integrating impact of varying client factors and contexts.






3. Articulate how this case demonstrates how you “perform interventions that are unique to school systems while integrating impact of varying client factors and contexts.” (average word guideline–500)








A)

B)

C)

4.Mentor





6. Briefly describe how the knowledge acquired from this mentoring activity influenced your service delivery with clients, specific to your ability to “perform interventions that are unique to school systems while integrating impact of varying client factors and contexts.” (average word guideline–200)


SELF-ANALYSIS OF VIDEO RECORDINGBack to Criteria


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

permissions should be obtained by applicant whenever engaging a client in a video-taped session.

1.Age of Client

Client Diagnosis(es)

Setting for Evaluation

Date of Video Recording

2. Provide a brief summary of the video contents and how it demonstrates your ability to “perform interventions that are unique to school systems while integrating impact of varying client factors and contexts.” (average word guideline–200)


3. After reviewing this video, 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)



Criterion 8—Intervention: Critical ReasoningSelects, plans, and modifies interventions in school systems based on evidence and evaluation data.






3. Articulate how this case demonstrates your ability to “select, plan, and modify interventions in school systems based on evidence and evaluation data.” (average word guideline–500)


FORMAL SPECIALIZED CONSULTATION FOR INTERVENTIONBack to Criteria








B)

C)



4. Summarize how this professional development activity influenced your ability to “select, plan, and modify interventions in school systems based on evidence and evaluation data.” (average word guideline–400)








A)

B)

C)

4.Mentor





6. Briefly describe how the knowledge acquired from this mentoring activity influenced your service delivery with clients, specific to your ability to “select, plan, and modify interventions in school systems based on evidence and evaluation data.” (average word guideline–200)





program.



3. Describe how this program development activity, including description of resources used, demonstrates your ability to “select, plan, and modify interventions in school systems based on evidence and evaluation data.” (average word guideline–500)



5. Describe how this research demonstrates your ability to “select, plan, and modify interventions in school systems based on evidence and evaluation data.” (average word guideline–400)



Criterion 9—PsychosocialRecognizes immediate and long-term implications of psychosocial issues related to conditions found in clients in school systems and modifies therapeutic approach and occupational therapy service delivery accordingly.






3. Articulate how this case demonstrates your ability to “recognize immediate and long-term implications of psychosocial issues related to conditions found in clients in school systems and modify therapeutic approach and occupational therapy service delivery accordingly.” (average word guideline–500)


FORMAL SPECIALIZED CONSULTATION FOR PSYCHOSOCIALBack to Criteria








B)

C)



4. Summarize how this professional development activity influenced your ability to “recognize immediate and long-term implications of psychosocial issues related to conditions found in clients in school systems and modify therapeutic approach and occupational therapy service delivery accordingly.” (average word guideline–400)








A)

B)

C)

4.Mentor





6. Briefly describe how the skills acquired from this mentoring activity influenced your service delivery with clients, specific to your ability to “recognize immediate and long-term implications of psychosocial issues related to conditions found in clients in school systems and modify therapeutic approach and occupational therapy service delivery accordingly.” (average word guideline–350)





program.



3. Describe how this program development activity, including description of resources used, demonstrates your ability to “recognize immediate and long-term implications of psychosocial issues related to conditions found in clients in school systems and modify therapeutic approach and occupational therapy service delivery accordingly.” (average word guideline–500)



5. Describe how this research demonstrates your ability to “recognize immediate and long-term implications of psychosocial issues related to conditions found in clients in school systems and modify therapeutic approach and occupational therapy service delivery accordingly.” (average word guideline–400)


FORMAL SPECIALIZED CONSULTATIONBack to Criteria

Criterion 11—Establishes NetworksEstablishes and collaborates with referral sources and stakeholders to help the client and relevant others achieve outcomes that support health and participation in the area of school systems.







B)

C)



4. Summarize how this professional development activity influenced your ability to “establish and collaborate with referral sources and stakeholders to help the client and relevant others achieve outcomes that support health and participation in the area of school systems.” (average word guideline–400)


MARKETING ACTIVITIESBack to Criteria


Type of media used for marketing: (check all that apply)☐ Presentation to potential referral source audience☐ Presentation to potential clients☐ Participation in community event such as health fairs☐ Speaking to community groups☐ Development and dissemination of marketing materials (e.g., brochures, Web sites,

podcasts)☐ Participation in media interview (e.g., television news, newspaper)☐ Other

1.Target Audience of Marketing

Date(s) of Marketing EffortsApproximate Total Hours Engaged in Marketing Activity

2. Provide a brief summary of the marketing activity. (average word guideline–50)

3. Applicant’s objectives for the marketing. List no more than 3.

A)

B)

C)


4. Describe how this marketing activity demonstrates how you “establish and collaborate with referral sources and stakeholders to help the client and relevant others achieve outcomes that support health and participation in the area of school systems.” (average word guideline–200)


PRESENTATIONBack to Criteria


Type of presentation:☐ In-service to professionals☐ Academic program lecture☐ Professional level workshop (e.g., state conference) ☐ Community

1. Presentation information.

Title

Target Audience

Date and Time of Presentation

2. Brief description of the presentation, including content focus. (average word guideline–50)

3. Applicant’s objectives for networking. Objectives must have been met by time of application. Please list no more than 3.A)

B)

C)


4. Describe how networks were established or strengthened through this presentation and any changes which have occurred as a result of your presentation. (average word guideline–200)


VOLUNTEER LEADERSHIPBack to Criteria


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

the certification area. 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 “establish and collaborate with referral sources and stakeholders to help the client and relevant others achieve outcomes that support health and participation in the area of school systems.” (average word guideline–200)


ADVOCACY EFFORTSBack to Criteria

Criterion 12— Advocating for ChangeInfluences services for clients (person, organization, population) in school systems through independent or collaborative education or advocacy activities.

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)


3. Discuss the results, outcomes, or progress toward change affected by this advocacy effort that demonstrates how you “influence services for clients (person, organization, population) in school systems through independent or collaborative education or advocacy activities.” (average word guideline–350)


ADVOCACY CASE STUDYBack to Criteria


Guidelines Efforts toward change that influence access to services or 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)


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 “influence services for clients (person, organization, population) in school systems through independent or collaborative education or advocacy activities.” (average word guideline–500)


PRESENTATIONBack to Criteria


Type of presentation:☐ In-service to professionals☐ Academic program lecture☐ Professional level workshop (e.g., state conference) ☐ Community

1. Presentation information.

Title

Target Audience

Date and Time of Presentation

2. Brief description of the presentation, including content focus. (average word guideline–50)

3. Applicant’s objectives for advocacy. Objectives must have been met by time of application. Please list no more than 3.A)

B)

C)


4. Describe how this presentation demonstrates that you “influence services for clients (person, organization, population) in school systems through independent or collaborative education or advocacy activities.” (average word guideline–200)


PUBLIC AWARENESS EFFORTSBack to Criteria


Guidelines Development of public awareness media for a broad audience to promote topic(s) relevant to the

specialty area.

Type of media developed: (check all that apply)☐ Presentation to potential referral source audience☐ Presentation to potential clients☐ Participation in community event, such as health fairs☐ Speaking to community groups☐ Development and dissemination of marketing materials (e.g., brochures, Web sites,

podcasts)☐ Participation in media interview (e.g., television news, newspaper)☐ Other

1. Target audience(s) of public awareness.Target Audience of Public Awareness EffortsDate(s) of Public Awareness ActivityApproximate Total Hours Engaged in Public Awareness Activity(ies)

2. Brief Summary of the Public Awareness Message (average word guideline–50)

3. Applicant’s objectives for advocacy/change. List no more than 3.

A)

B)

C)


4. Summarize the changes that have occurred (or progress toward change) as a result of your public awareness efforts and how this activity demonstrates that you “influence services for clients (person, organization, population) in school systems through independent or collaborative education or advocacy activities.” (average word guideline–200)


VOLUNTEER LEADERSHIPBack to Criteria


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 “influence services for clients (person, organization, population) in school systems through independent or collaborative education or advocacy activities.” (average word guideline–400)


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