FLORIDA A&M UNIVERSITY SCHOOL OF ALLIED HEALTH SCIENCES Division of Occupational Therapy APPLICATION FOR ADMISSION Master of Science in Occupational Therapy APPLICATION FOR ADMISSION TO: FOR OFFICE USE ONLY MSOT Program Florida A&M University Division of Occupational Therapy Ware-Rhaney Building, Room 318 Tallahassee, Florida 32307 Date Received: ______________ FAMU Student: First Time Applying: YES YES NO NO FLORIDA A&M UNIVERSITY Division of Occupational Therapy APPLICATION FOR ADMISSION MASTER OF SCIENCE IN OCCUPATIONAL THERAPY Please TYPE and return this application to the Admissions Coordinator, Florida A&M University, Division of Occupational Therapy, Tallahassee, Florida 32307-3200 Have you previously applied for admission to the Florida A&M MSOT Program? Yes________ No _________ BIOGRAPHICAL DATA Name: Last: ___________________ First: __________________ Middle: ______________ Maiden: ___________ Social Security Number (Last Four Digits): _____ _____ _____ ______ Ethnic Background: Federal law requires the University to report the ethnicity of all U.S. citizens and Aliens in the following 5 categories: Please CIRCLE ONE: Black, Non-Hispanic Hispanic Asian or Pacific Islander American Indian or Alaskan Native Caucasian Nation of Citizenship: _________________________ Country of Birth: ___________________________ Give alien registration card number if you are NOT a citizen but have permanent residency status: _____________________ Are you a resident of Florida? Yes_____________ How Long? __________________ No _______________ PRESENT ADDRESS: City:________________________________ State: ____________________ County: __________________ Zip:___________ 2 Email:__________________________________________ Telephone: ____________________________________________ Place of Employment: _____________________________________ Phone Number: _________________________________ PERMANENT ADDRESS: City: ________________________________ State: ____________________ County: __________________ Zip: ___________ Indicate preference of receipt of your mail: Present Address________________ Permanent Address ________________ EDUCATIONAL BACKGROUND List all undergraduate colleges, universities, or professional schools, beginning with the most current or most recently attended institution. Please provide an OFFICIAL copy of your transcript(s). If you have attended institution(s) other than FAMU, please provide an OFFICIAL copy of course descriptions (university or college catalog) as well as an OFFICIAL copy of your transcript. Institution Address Major 3 Attendance To From Degree or Certification Date Anticipated Date of Enrollment in FAMU MSOT Program: Summer ______ (Year) 20___ Fall____ (Year) 20___ References: List the names of the three persons to whom you have sent recommendation forms and their relationship to you. (PLEASE print clearly) 1. __________________________________________________________________ 2. __________________________________________________________________ 3. __________________________________________________________________ List any volunteer and/or observation hours. You MUST submit letters from registered/licensed Occupational Therapists, on their company letterhead, to substantiate hours (30) of observation completed: 1. __________________________________________________________________ 2. __________________________________________________________________ 3. __________________________________________________________________ 4. __________________________________________________________________ 5. __________________________________________________________________ List any organizations or community programs in which you have participated. If they could be resources for student fieldwork and / or research projects, please so indicate. 1. __________________________________________________________________ 2. __________________________________________________________________ 3. __________________________________________________________________ 4. __________________________________________________________________ 5. __________________________________________________________________ GRE/TOEFL Exams Taken: GRE: Yes ______ No ______ Date: ___________ TOEFL: Yes ______ No_____ Date ________ 4 Did you request that your official scores be sent to the FAMU Graduate School ? Yes ______ No _______ The following faculty provided me with information/or advisement in regard to the FAMU MSOT Program: 1. __________________________________________________________________ 2. __________________________________________________________________ Have you ever been placed on probation or dismissed from an Occupational Therapy Program? Yes _______ No _______ If Yes, please explain _____________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Have you ever been convicted of a criminal offense? Yes _____ No _____ If yes, please be conscious that an official background check is required of all students before they can begin their fieldwork experiences. Also, you will need to submit appropriate information to the National Board for Certification of Occupational Therapy (NBCOT) for an “Early Determination Review”. Per the NBCOT: An individual who is considering entering an educational program or has already entered an education program can have his or her background reviewed prior to actually applying for the exam by requesting an early determination review. The fee for this review is $100.00. In this “early determination review” process, the NBCOT may give early or prior approval to take the certification exam, as it pertains to good moral character, provided that the information reviewed is not found to be in violation of any of the principles of the Code of Conduct. This review is intended to provide you with valuable information regarding your potential to practice, to acquire licensure and national certification upon graduation and is not intended as a punitive or discrimination measure for applicants having a criminal conviction. Results of an “Early Determination” NBCOT review need not be submitted to the program. If results indicate that certification or licensure may be a problem that applicant may be advised to withdraw from the admission process. NOTE: If you have additional questions or would like additional information you may contact the Credentialing Services at NBCOT, located at 800 Frederick Avenue, Suite 200, Gaithersburg, Maryland, 20877; phone 301-990-7979 or contact character.review@nbcot.org. 5 EMPLOYMENT HISTORY Complete the following employment history form. Include time spent doing volunteer work. (Add additional pages if needed) 1. Employer: _____________________________________ Date:_______________ Hrs./Wk:_________________ Address: City: State: Zip: ______________________________________________________________________ Title: ________________________________________________________________________________________ Overview of Duties: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Hours of Volunteer Work: _____________________________________________________________________ 2. Employer: _____________________________________ Date:_______________ Hrs./Wk:_________________ Address: City: State: Zip: ______________________________________________________________________ Title: ________________________________________________________________________________________ Overview of Duties: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Hours of Volunteer Work: _____________________________________________________________________ 3. Employer: _____________________________________ Date:_______________ Hrs./Wk:_________________ Address: City: State: Zip: ______________________________________________________________________ Title: ________________________________________________________________________________________ Overview of Duties: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Hours of Volunteer Work: _____________________________________________________________________ 6 ADMISSIONS ESSAY Attach a TYPED, double-spaced, admissions essay. The purpose of the essay is to evaluate your understanding of and commitment to the profession, in addition to your thinking and writing ability. In this essay you should: 1. Discuss your perceptions about the impact of occupational therapy on the health and well being of individuals and/or groups. 2. Discuss why and how occupational therapy will meet your personal and professional goals. 3. Discuss your participation in a meaningful occupation that has influenced your own personal and/or professional growth. Note: SIGN AND DATE the bottom of the essay. PRE-REQUSITE COURSES: The following pre-requisite courses must have been taken within the past 10 years and the overall GPA for them must be 3.0 or better. Indicate where and when taken, and the grades you received. Course Title Credits Taken at Date(mm/dd/yy) Grade Human Growth and Development 3 Intro to Anthropology or Sociology 3 Intro to Psychology 3 Abnormal Psychology 3 General Biology with Lab 4 Chemistry (“Fundamentals” or higher) 3 College Physics I 3 College Physics Lab 1 Anatomy and Physiology I 3 Anatomy and Physiology I Lab 1 Anatomy and Physiology II 3 Anatomy and Physiology II Lab 1 Introduction to Statistics 3 Introduction to Research 3________________________________________ Total required pre-requisite credits 37 7 PLEDGE BEFORE A NOTARY PUBLIC “I certify that the information provided on this application and attached documents herein are true and accurate to the best of my knowledge. I understand that withholding information or giving misleading information, omissions or falsifications may result in a withdrawal of an offer to accept me. I understand that it is my responsibility to ensure that application materials are received by the identified deadline date. I further understand that I must request and provide official transcripts from all previous colleges and universities attended before acceptance into the Florida A&M University MSOT program.” ______________________________________ Signature of Applicant __________________ Date Your NOTARIZED signature is REQUIRED Sworn to and Subscribed before me this _________________ Day of _________, 20____ _______________________________________ Notary Public My Commission Expires ___________________ SEAL 8 FLORIDA A&M UNIVERSITY School of Allied Health Sciences Lewis-Beck Bldg., #318 Division of Occupational Therapy Tallahassee, Florida 32307-3500 (850) 412-7865 Applicant: Please complete the following and sign. Pursuant to the Family Rights and Privacy Act (Buckley Amendment) signed into law December 13, 1974. I, __________________________________, do do not waive my right to Name of Applicant inspect and review this and other recommendation forms upon completion. ________________________________________ Applicant Signature Evaluator: Thank you for your evaluation of this applicant, who has applied for admission to the Master of Science in Occupational Therapy (MSOT) program at FAMU. The applicant’s file will not be acted upon until we receive this form, so we ask that you return it as soon as possible to the address above. It is important that you answer each question. If you need more space, please attach an additional page for further comments. Again, thank you for your feedback. 1. Please rate the applicant’s abilities in the following areas using the scale below: 4 = Outstanding; 3 = Above Average; 2 = Average; 1 = Below Average 4 Judgment – Common sense, able to accept suggestions Assertiveness – Nonabrasive, firmness in stating position Knowledge , Interest in Occupational Therapy – Depth of commitment Demeanor – Warm, responsive to others’ moods, positive Industry – Perseverance, endurance, works hard Reliability – Dependability, you can count on him or her Leadership – Earns respect by example, steps in to organize Self-understanding – Strengths, knows and works on weaknesses Personal Appearance – Appropriate for whatever occasion Cooperation – Ability to work with others Written Communication – Clear , concise 2. How long and in what capacity have you known the applicant? ___________________________________________________________________ ___________________________________________________________________ 3. What is your relationship to the applicant? 9 3 2 1 4. What do you feel are the applicant’s major strengths that would make him or her an effective occupational therapist? 5. What do you feel are the applicant’s weaknesses or areas that need development? 6. If you were a member of the admissions committee, how would you rate this candidate? I would highly recommend this applicant. I would recommend this applicant, but with some reservations. I would not be able to recommend this applicant Name (Printed)__________________________________________________________ Position/Employer _______________________________________________________ Address __________________________________ Telephone ____________________ ___________________________ ___________________________ Email ____________________________________ Signed ___________________________________________ 10 Date _____________