SCHOOL SYSTEMS SPECIALTY CERTIFICATION
Occupational Therapist
Table of Contents: ACTIVITY EVIDENCE FORMS
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 application to
https://www.filesdirect.com/AOTACertification.
Please do not include unused forms.
Criterion 1: Knowledge: Diagnostic
Considerations
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
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
Expert Witness
Formal Learning– Minimum 10 contact hours
needed
Independent Learning–Minimum 10 contact hours
needed
Publication – Peer-Reviewed
Criterion 2: Knowledge: Evaluation
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


Expert Witness
Formal Learning–Minimum 10 contact hours
needed
Independent Learning–Minimum 10 contact hours
needed
Publication – Peer-Reviewed
Criterion 6: Evaluation: Critical Reasoning
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Critical Reasoning Scenarios (2)
o List of Assessments for CR Scenarios
Formal Specialized Consultation for Evaluation
Program Development
Research
Criterion 7: Intervention: Performance Skills
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Client-Based Case Study
Mentee (does not include supervisory relationship)
Self-Analysis of Video Recording
Criterion 8: Intervention: Critical Reasoning
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Client-Based Case Study
Formal Specialized Consultation for Intervention
Mentee (does not include supervisory relationship)
Program Development
Research
Criterion 3: Knowledge: Intervention




Expert Witness
Formal Learning–Minimum 10 contact hours
needed
Independent Learning–Minimum 10 contact hours
needed
Publication – Peer-Reviewed
Criterion 4: Knowledge: Regulation & Payers




Expert Witness
Formal Learning–Minimum 3 contact hours needed
Independent Learning–Minimum 3 contact hours
needed
Publication – Peer-Reviewed
Criterion 5: Evaluation: Performance Skills



Client-Based Case Study
Mentee (does not include supervisory relationship)
Self-Analysis of Video Recording
Criterion 9: Psychosocial Critical Reasoning
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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
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Formal Specialized Consultation
Marketing Activities
Presentation
Volunteer Leadership
Criterion 12: Advocating for Change
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Advocacy Efforts
Advocacy Case Study
Presentation
Public Awareness Efforts
Volunteer Leadership
EXPERT WITNESS/TESTIMONY
Back to Criteria
Criterion 1–Knowledge: Diagnostic Considerations
Demonstrates 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 LEARNING
Back to Criteria
Criterion 1–Knowledge: Diagnostic Considerations
Demonstrates knowledge of primary and secondary conditions that impact occupational
engagement related to school systems.
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)
4. 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)
5. Submit documentation that verifies completion of the activity, such as certificate of completion or
unofficial transcript. Not required for AOTA courses.
INDEPENDENT LEARNING
Back to Criteria
Criterion 1–Knowledge: Diagnostic Considerations
Demonstrates knowledge of primary and secondary conditions that impact occupational
engagement related to school systems.
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 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.
5. Describe the relevance of the independent learning activity to your practice in school systems.
(average word guideline–200)
6. 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)
PUBLICATION – PEER-REVIEWED
Back to Criteria
Criterion 1–Knowledge: Diagnostic Considerations
Demonstrates knowledge of primary and secondary conditions that impact occupational
engagement related to school systems.
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)
EXPERT WITNESS/TESTIMONY
Back to Criteria
Criterion 2—Knowledge: Evaluation
Demonstrates knowledge of relevant evidence specific to evaluation in 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 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)
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 LEARNING
Back to Criteria
Criterion 2—Knowledge: Evaluation
Demonstrates knowledge of relevant evidence specific to evaluation in school systems.
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)
4. 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)
5. Submit documentation that verifies completion of the activity, such as certificate of completion or
unofficial transcript. Not required for AOTA courses.
INDEPENDENT LEARNING
Back to Criteria
Criterion 2—Knowledge: Evaluation
Demonstrates knowledge of relevant evidence specific to evaluation in school systems.
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 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.
5. Describe the relevance of the independent learning activity to your practice in school systems.
(average word guideline–200)
6. 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)
PUBLICATION – PEER-REVIEWED
Back to Criteria
Criterion 2—Knowledge: Evaluation
Demonstrates knowledge of relevant evidence specific to evaluation in school systems.
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 relevant
evidence specific to evaluation in school systems. (average word guideline–200)
EXPERT WITNESS/TESTIMONY
Back to Criteria
Criterion 3—Knowledge: Intervention
Demonstrates knowledge of relevant evidence specific to intervention in 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 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)
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 LEARNING
Back to Criteria
Criterion 3—Knowledge: Intervention
Demonstrates knowledge of relevant evidence specific to intervention in school systems.
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)
4. 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)
5. Submit documentation that verifies completion of the activity, such as certificate of completion or
unofficial transcript. Not required for AOTA courses.
INDEPENDENT LEARNING
Back to Criteria
Criterion 3—Knowledge: Intervention
Demonstrates knowledge of relevant evidence specific to intervention in school systems.
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 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.
5. Describe the relevance of the independent learning activity to your practice in school systems.
(average word guideline–200)
6. 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)
PUBLICATION – PEER-REVIEWED
Back to Criteria
Criterion 3—Knowledge: Intervention
Demonstrates knowledge of relevant evidence specific to intervention in school systems.
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 relevant
evidence specific to intervention in school systems. (average word guideline–200)
EXPERT WITNESS/TESTIMONY
Back to Criteria
Criterion 4—Knowledge: Regulation & Payers
Demonstrates knowledge of laws and regulations relevant to school systems, including payer
sources.
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 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)
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 LEARNING
Back to Criteria
Criterion 4—Knowledge: Regulation & Payers
Demonstrates knowledge of laws and regulations relevant to school systems, including payer
sources.
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 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)
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)
5. Submit documentation that verifies completion of the activity, such as certificate of completion or
unofficial transcript. Not required for AOTA courses.
INDEPENDENT LEARNING
Back to Criteria
Criterion 4—Knowledge: Regulation & Payers
Demonstrates knowledge of laws and regulations relevant to school systems, including payer
sources.
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 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 3-hour requirement.
5. Describe the relevance of the independent learning activity to your practice in school systems.
(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)
PUBLICATION – PEER-REVIEWED
Back to Criteria
Criterion 4—Knowledge: Regulation & Payers
Demonstrates knowledge of laws and regulations relevant to school systems, including payer
sources.
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 laws and
regulations relevant to school systems, including payer sources.” (average word guideline–200)
CLIENT-BASED CASE STUDY
Back to Criteria
Criterion 5—Evaluation: Performance Skills
Administers 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–MENTEE
Back to Criteria
Criterion 5—Evaluation: Performance Skills
Administers standardized assessments specific to school systems, consistently integrating
clinical observations throughout the evaluation process.
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 Mentor
Contact 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 RECORDING
Back to Criteria
Criterion 5—Evaluation: Performance Skills
Administers standardized assessments specific to school systems, consistently integrating
clinical observations throughout the evaluation process.
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 SCENARIOS
Back to Criteria
Criterion 6—Evaluation: Critical Reasoning
Synthesizes 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 I
ASSESSMENT 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 6
Specialty 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 structures
2. Areas of Occupation - Activities of Daily Living, Instrumental Activities of Daily Living, Rest
and Sleep, Education, Work, Play, Leisure, Social Participation
3. Client Factors - Values, Beliefs, Spirituality, Body Functions, Body Structures
4. Context - Cultural, Personal, Physical, Social, Temporal, Virtual
5. Performance Patterns - Habits, Routines, Roles, Rituals
6. Performance Skills - Sensory-Perceptual, Motor and Praxis, Emotional Regulation, Cognitive,
Communication and Social Skills
OT Domain
Assessments
Adaptive Behavior Assessment SystemSecond Edition (ABAS-II)
Assessment, Evaluation, and Programming
System for Infants and Children-Second
Edition (AEPS®)
Battelle Developmental Inventory, 2nd
Edition (BDI-2™)
Beery-Buktenica Test of Visual-Motor
Integration, 6th Edition (VMI)
Bruininks-Oseretsky Test of Motor
Proficiency-2nd Edition (BOT-2)
Ages or Grades
References
Birth-89 years
Harrison, P., & Oakland, T. (2003). Adaptive
behavior assessment system (2nd ed.). Antonio,
TX: Psychological Corporation.
Bricker, D. (Ed). (2002). Assessment,
evaluation, and programming system (2nd ed.).
Baltimore, MD: Paul H. Brookes.
Newborg, J. (2005). Battelle developmental
inventory (2nd ed.). Itasca, IL: Riverside
Publishing.
Beery, K., & Beery, N. (2010). The beerybuktenica developmental test of visual motor
integration (6th ed). Bloomington, MN: Pearson.
Bruininks, R., & Bruininks, B. (2005).
Bruininks-oseretsky test of motor proficiency
(2nd ed.). Minneapolis, MN: NCS Pearson.
0-6 years
0-8 years
2-100 years
4-21 years
1
2
X
3
4
5
6
X
X
X
X
X
OT Domain
Assessments
Canadian Occupational Performance
Measure 4th Edition (COPM)
Carolina Curriculum for Preschoolers with
Special Needs, Second Edition
Ages or Grades
References
8 years-adult
Law, M., Baptiste, S., Carswell, A., McColl, M.,
Polatajko, H., & Pollock, N. (2005). Canadian
occupational performance measure. Ontario,
Canada: CAOT Publications.
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.
Keller, J., Kafkes, A., Basu, S., Federico, J., &
Kielhofner, G. (2005). Child occupational self
assessment. Chicago, IL: MOHO Clearinghouse.
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.
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.
Hammill, D., Pearson, N., & Voress, J. (1993).
Developmental test of visual perception (2nd
ed.). Austin, TX: Pro-ed.
Reynold, C., Voress, J., & Pearson, N. (2002).
Developmental test of visual perceptionadolescent and adult. Austin, TX: Pro-ed.
Amundson, S. (1995). Evaluation tool of
children’s handwriting.
Homer, AK: O.T. Kids.
Korsten, J., Foss, T., & Berry, L. (2007). Every
move counts: Clicks and chats. Lee’s Summit,
MO: EMC.
Russell, D., Rosenbaum, J., Avery, L., & Lane,
M. (2002). Gross motor function measure.
Hoboken, NJ: Wiley Blackwell Publishing.
2-5 years’
developmental age
Child Occupational Self Assessment
(COSA)
7-17 years
Children's Assessment of Participation and
Enjoyment (CAPE) & Preferences for
Activities of Children (PAC)
6-21 years
Children's Assessment of Participation and
Enjoyment (CAPE) & Preferences for
Activities of Children (PAC)
6-21 years
Developmental Test of Visual Perception,
2nd Edition (DVPT-2)
4-10 years
Developmental Test of Visual PerceptionAdolescent and Adult (DTVP-A)
11-74 years
Evaluation Tool of Children’s Handwriting
(ETCH)
Grades 1-6
Every Move Counts, Clicks & Chats
Gross Motor Function Measure (GMFM-66
and GMFM-88)
All ages
Less than 5 years
developmentally
1
2
3
4
5
6
X
X
X
X
X
X
X
X
X
X
X
X
X
X
OT Domain
Assessments
McMaster Handwriting Assessment
Protocol -2nd edition
Miller Function and Participation Scales
Ages or Grades
References
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.
Miller, L. (2006). Miller function and
participation scales. San Antonio, TX: Harcourt
Assessment.
Reisman, J. (1999). Minnesota handwriting
assessment. San Antonio, TX: Psychological
Corporation.
Colarusso, R., & Hamill, D. (2003). Motor-free
visual perception test (3rd ed.). Novato, CA:
Academic Therapy Publications.
Baron, K., Kielhofner, G., Iyenger, A.,
Goldhammer, V., & Wolenskil, J. (2006).
Occupational self assessment. Chicago, IL:
MOHO Clearninghouse.
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.
Folio, M. R., & Fewell, R. R. (2000). Peabody
developmental motor scales (2nd ed.). San
Antonio, TX: Psychological Corporation.
Haley, S., Coster, W., Ludlow, L., Haltiwanger,
J., & Andrellos, P. (1992). Pediatric evaluation
of disability inventory. Boston, MA: Trustees of
Boston University.
Missiuna, C., Pollock, N., & Law, M. (2004).
Perceived efficacy and goal setting system. San
Antonio, TX: Psychological Corporation.
Olsen, J. (2005). The print tool. Cabin John,
MD: Handwriting Without Tears.
2.6-7.11 years
Minnesota Handwriting Assessment
Grades 1-2
Motor-Free Visual Perception Test-3
(MVPT-3)
4-12 years
Occupational Self Assessment (OSA)
12+ years
Occupational Therapy Psychosocial
Assessment of Learning, Version 2.0 (OT
PAL)
6-12 years
Peabody Developmental Motor Scales
(PDMS-2)
Pediatric Evaluation of Disability
Inventory (PEDI)
Perceived Efficacy and Goal Setting
System (PEGS)
Print Tool
Birth-5 years
6 months-7 years
developmentally
5-10 years
6 years and up
1
2
3
4
5
6
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
OT Domain
Ages or Grades
References
School Assessment of Motor and Process
Skills, 2nd edition (School AMPS)
Assessments
3-12 years
School Function Assessment (SFA)
Grades K-6
School Setting Interview
Grades K-12
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.
Coster, W., Deeney, T., Haltiwanger, J., &
Haley, S. (1998). School function assessment.
San Antonio, TX: The Psychological
Corporation.
Hemmingsson, H., Egilson, S., Hoffman, O., &
Kielfhofner, G. (2005). The school setting
interview. Chicago, IL: MOHO Clearinghouse.
Parham, L., Ecker, C. , Kuhaneck, H., Henry,
D., & Glennon, T. (2007). Sensory processing
measure. Los Angeles, CA: Western
Psychological Services.
Ecker, C. , Parham, L., Kuhaneck, H., Henry,
D., & Glennon, T. (2010). Sensory processing
measure-preschool. Los Angeles, CA: Western
Psychological Services.
Dunn, W. (1999). Sensory profile. San
Antonio, TX: Psychological Corporation.
Brown, C., & Dunn, W. (2002).
Adolescent/adult sensory profile. San Antonio,
TX: Psychological Corporation.
Dunn, W. (2006). Sensory profile-school
companion. San Antonio, TX: Psychological
Corporation.
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.
Thompson, J., Bryant, B., Campbell, E., & Craig
, E.(2010). Supports intensity scale.
Washington DC: American Association on
Intellectual and Developmental Disabilities.
Sensory Processing Measure
Sensory Processing Measure-Preschool
Sensory Profile
Grades K-6
2-5 years
3-10 years
Sensory Profile: Adolescent/Adult
11 years-adult
Sensory Profile-School Companion
3-11 years
Short Child Occupational Profile (SCOPE)
Birth-21 years
Supports Intensity Scale
16 years-adult
1
2
3
4
5
X
X
6
X
X
X
X
X
X
X
X
X
X
X
X
X
OT Domain
Assessments
Test of Environmental Supportiveness
(TOES)
Ages or Grades
References
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.
Milone, M. (2007). Test of handwriting skillsrevised. Novato, CA: Academic Therapy
Publications.
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.
Martin, N. A.. (2006). Test of visual perceptual
skills (3rd ed.). Novato, CA: Academic Therapy
Publications.
Linder, T. W. (2008). Trans-disciplinary playbased assessment (2nd ed). Baltimore, MD:
Paul H. Brookes.
Sparrow, S. S., Cicchetti, D. V., & Balla, D. A.
(2007). The vineland adaptive behavior scales
(2nd ed.). Circle Pines, MN: AGS Publishing.
Moore-Corner, R. A., Kielhofner, G., & Olson, L.
(1998). Work environment impact scale
(Version 2.0). Chicago: University of Illinois.
Braveman, B., Robson, M., Velozo, C.,
Kielhofner, G. F., Forsyth, K., & Kerschbaum, J.
(2005). Worker role interview (Version 10.0).
Chicago: University of Illinois.
Test of Handwriting Skills-Revised (THS-R)
5-18.11 years
Test of Playfulness (ToP) (Version 4.0—5/05)
6 months-18 years
Test of Visual Perceptual Skills, 3rd Edition
4-18 years
Transdisciplinary Play-Based Assessment
2nd Edition
Birth-6 years
Vineland Adaptive Behavior Scales, 2nd
Edition (Vineland-II)
Work Environment Impact Scale (WEIS)
Worker Role Interview (WRI)
Birth-90 years
Adolescent-young
adult in vocational
training
Adolescent-young
adult in vocational
training
1
2
X
3
4
5
6
X
X
X
X
X
X
X
X
X
X
FORMAL SPECIALIZED CONSULTATION FOR EVALUATION
Back to Criteria
Criterion 6—Evaluation: Critical Reasoning
Synthesizes and interprets assessment data and clinical observations related to the client,
context, and performance in school systems.
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 Completed
Date(s) of Consultation
No. 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 DEVELOPMENT
Back to Criteria
Criterion 6—Evaluation: Critical Reasoning
Synthesizes and interprets assessment data and clinical observations related to the client,
context, and performance in school systems.
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)
RESEARCH
Back to Criteria
Criterion 6—Evaluation: Critical Reasoning
Synthesizes and interprets assessment data and clinical observations related to the client,
context, and performance in school systems.
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)
CLIENT-BASED CASE STUDY
Back to Criteria
Criterion 7—Intervention: Performance Skills
Performs interventions that are unique to school systems while integrating impact of varying
client factors and contexts.
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 “perform interventions that are unique to school
systems while integrating impact of varying client factors and contexts.” (average word guideline–
500)
MENTORING RELATIONSHIP–MENTEE
Back to Criteria
Criterion 7—Intervention: Performance Skills
Performs interventions that are unique to school systems while integrating impact of varying
client factors and contexts.
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 Mentor
Contact 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 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 RECORDING
Back to Criteria
Criterion 7—Intervention: Performance Skills
Performs interventions that are unique to school systems while integrating impact of varying
client factors and contexts.
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)
CLIENT-BASED CASE STUDY
Back to Criteria
Criterion 8—Intervention: Critical Reasoning
Selects, plans, and modifies interventions in school systems based on evidence and
evaluation data.
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 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 INTERVENTION
Back to Criteria
Criterion 8—Intervention: Critical Reasoning
Selects, plans, and modifies interventions in school systems based on evidence and
evaluation data.
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 Completed
Date(s) of Consultation
No. 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 “select, plan, and
modify interventions in school systems based on evidence and evaluation data.” (average word
guideline–400)
MENTORING RELATIONSHIP–MENTEE
Back to Criteria
Criterion 8—Intervention: Critical Reasoning
Selects, plans, and modifies interventions in school systems based on evidence and
evaluation data.
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 Mentor
Contact 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 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 DEVELOPMENT
Back to Criteria
Criterion 8—Intervention: Critical Reasoning
Selects, plans, and modifies interventions in school systems based on evidence and
evaluation data.
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 “select, plan, and modify interventions in school systems based on
evidence and evaluation data.” (average word guideline–500)
RESEARCH
Back to Criteria
Criterion 8—Intervention: Critical Reasoning
Selects, plans, and modifies interventions in school systems based on evidence and
evaluation data.
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 “select, plan, and modify interventions in
school systems based on evidence and evaluation data.” (average word guideline–400)
CLIENT-BASED CASE STUDY
Back to Criteria
Criterion 9—Psychosocial
Recognizes 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.
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 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 PSYCHOSOCIAL
Back to Criteria
Criterion 9—Psychosocial
Recognizes 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.
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 Completed
Date(s) of Consultation
No. 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 “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)
MENTORING RELATIONSHIP–MENTEE
Back to Criteria
Criterion 9—Psychosocial
Recognizes 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.
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 Mentor
Contact 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 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 DEVELOPMENT
Back to Criteria
Criterion 9—Psychosocial
Recognizes 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.
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 “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)
RESEARCH
Back to Criteria
Criterion 9—Psychosocial
Recognizes 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.
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 “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 CONSULTATION
Back to Criteria
Criterion 11—Establishes Networks
Establishes 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.
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 Completed
Date(s) of Consultation
No. 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 “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 ACTIVITIES
Back to Criteria
Criterion 11—Establishes Networks
Establishes 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.
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 Efforts
Approximate 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)
PRESENTATION
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Criterion 11—Establishes Networks
Establishes 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.
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 LEADERSHIP
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Criterion 11—Establishes Networks
Establishes 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.
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 EFFORTS
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Criterion 12— Advocating for Change
Influences 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)
2. Applicant’s objectives for advocating for change. List no more than 3.
A)
B)
C)
No. of Hours
Involved
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 STUDY
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Criterion 12— Advocating for Change
Influences services for clients (person, organization, population) in school systems through
independent or collaborative education or advocacy activities.
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)
PRESENTATION
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Criterion 12— Advocating for Change
Influences services for clients (person, organization, population) in school systems through
independent or collaborative education or advocacy activities.
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 EFFORTS
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Criterion 12— Advocating for Change
Influences services for clients (person, organization, population) in school systems through
independent or collaborative education or advocacy activities.
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
Efforts
Date(s) of Public Awareness Activity
Approximate 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 LEADERSHIP
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Criterion 12— Advocating for Change
Influences services for clients (person, organization, population) in school systems through
independent or collaborative education or advocacy activities.
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)