Application And Renewal Guide

College of Occupational Therapists of Manitoba Quality Occupational Therapy - Accountable to Manitobans 2009 APPLICATION FOR RENEWAL OF REGISTRATION RENEWAL DEADLINE: Sunday, May 31, 2009* *PLEASE NOTE: The office will not be open on the weekend. Please ensure this form is received by Friday, May 29, 2009. Please refer to the Application Guide for further information and guidance, or contact the office to discuss your questions. 1) MEMBERSHIP STATUS: Select the appropriate renewal status for COTM and/or MSOT, and complete the sections indicated. COTM Renewal Status Renew as Practising Renew as Provisional Renew as Non-Practising Cancel Registration Complete Sections 1,2,3,4,5,6,7,8,9,10,11,13,15 1,2,3,4,5,6,7,8,9,10,11,13,15 1,2,3,4,5,6a,8,9,10,11,13,15 1,2,5,12 MSOT Renewal Status Join as a Full Member Join as Out of Province Member Continue Life Membership Complete Sections 1,2,3,13,14,15 1,2,3,13,14,15 1,2,3,13,14,15 2) DEMOGRAPHICS: Indicate necessary changes to demographic information below and complete blanks Name: Full Address: Member # Postal Code: Home Phone: Preferred Email: Work Phone: 3) CONTACT PREFERENCES: Answer ‘yes’ or ‘no’ to the following questions. a) For COTM members only: b) For MSOT members only: c) For MSOT members only: May COTM contact you via email? May MSOT contact you via email? Would you like to be on the MSOT mailing list? Yes Yes Yes No No No 4. EDUCATION UPDATES: Only complete if reporting new information. Submit a photocopy of any new degree(s) as evidence. a) Designation: Certificate/Diploma Research (thesis-based) Masters Bachelors Professional (course-based)Masters Doctorate b) Details: Title of Degree/Certificate/Diploma _____________________________________________________________________ Major Field ____________________________________________________________ Year of Graduation _______________ School ________________________________________________________________ Province/Country _________________ 5. OT EMPLOYMENT HISTORY: Provide details for where you worked LAST REGISTRATION YEAR (JUNE 1/2008 – MAY 31/2009) a) Check all of the following items that apply: i) I worked at least 700 hours (Provide details in section b) ii) I have changed employers during this period (Provide details in section b) iii) I have not worked at least 700 hours this period (Provide details in section b) iv) I was on leave of absence for more than 3 months (Provide dates in section b) v) My work included education or volunteer hours (Provide details in section b and attach proof) b) If applicable, provide details for your previous registration years’ work. If more space is required, attach a separate sheet to your form. Worksite Address Including Postal Code Dates of Employment Total hours worked (if less than 700) In calculating “total hours worked” subtract vacation days, sick days, leave of absence, etc. Total Hours FAILURE TO SUBMIT ALL DOCUMENTS FOR COTM RENEWAL BY MAY 31, 2009 WILL RESULT IN A REINSTATEMENT/LATE FEE 6. CURRENT OT EMPLOYMENT IN MANITOBA: Provide details for your work situation AS OF JUNE 1/2009: a) Choose one of the following descriptions that best suits your current work situation, then proceed as instructed. Working as an occupational therapist. (Please complete the remainder of this section) Unemployed and not seeking employment in occupational therapy. (Proceed to the next applicable section) Unemployed and seeking employment in occupational therapy. (Proceed to the next applicable section) Employed, but on leave of absence such as parental leave. (Proceed to the next applicable section) Employed, but not as an O.T. (Proceed to the next applicable section) b) Complete all fields for each employer. If more space is required, please attach a separate sheet to your form. Employer Address of Employer including postal code Work Phone Primary Secondary Tertiary □ Check here if same as in section 5 □ Check here if same as in section 5 □ Check here if same as in section 5 Scheduled hours [Primary - Most hours], [Secondary - Less hours], [Tertiary - Least hours]. If you have additional employers, attach a separate sheet to your renewal form. c) Complete all fields for each employer. See the Renewal Guide if clarification is required. Is the postal code for the employer the same as the postal code for your worksite? (worksite = where service is delivered) Primary site □ yes □ no □□ 20 Temporary Secondary site □ yes □ no □□ 40 Self-Employed Tertiary site □ yes □ no Employment Category (indicate one for each employment) Primary Employment 10 Permanent Secondary Employment 30 Casual Tertiary Employment □□ □□ □□ 60 Other Full/Part time Status (indicate one for each employment) Primary Employment 10 Full time □□ □□ □□□ 060 070 080 090 100 Secondary Employment □□ □□ □□□ 110 120 130 140 Tertiary Employment 20 Part time/Casual part time Position (indicate one for each employment) Primary Employment 10 Manager Secondary Employment Tertiary Employment 40 Educator 20 Professional leader/ Coordinator 30 Direct Service Provider 50 Researcher Employer Type (indicate one employer type for each employment) Primary Employment 010 020 030 040 050 Secondary Employment Tertiary Employment □□□ General Hospital Rehabilitation Facility Mental Health Hospital/Facility Residential Care Facility Assisted Living Residence Community Health Centre Visiting Agency/ Business Group Professional Practice/Clinic Solo Professional practice/Business Post-Secondary Educational Institute School or School Board Assoc/Gov’t /Para-Government Industry/Manufacturing & Commercial Other Employer type, not described Area of Practice (indicate one for each employment) Primary Employment 010 020 030 040 050 □□□ 060 070 080 090 100 Secondary Employment □□□ 110 120 130 140 150 Tertiary Employment □□□ Mental Health Neurological System Musculoskeletal System Cardiovascular & Respiratory Digestive/Metabolic/Endocrine General Physical Health Vocational Rehabilitation Palliative Care Health Promotion & Wellness Other areas of Direct Service Service Administration Client Service Management Medical/Legal related Client Service Management Teaching Research 160 Other Area of Practice Geographical Area of Service Provision (indicate one for each employment) Primary Employment 01 02 03 □□ 04 05 06 Secondary Employment Eastman (North) Eastman (South) Central 07 08 09 □□ Parkland Nor-Man Interlake 10 11 12 Tertiary Employment Burntwood Churchill Manitoba 13 14 □□ Mixed Out of Province Winnipeg Brandon Assiniboine (excl. Brandon) Client Age Range Primary Employment 10 41 Preschool age Mixed Adults □□ 20 44 Secondary Employment School age All Ages 21 50 □□ □□ Tertiary Employment 30 98 □□ Seniors 65+ Mixed Pediatrics Other client age range Adults 18-64 40 Not working with clients Funding Source (indicate funding source for each employment) Primary Employment □□ Secondary Employment Tertiary Employment □□ FAILURE TO SUBMIT ALL DOCUMENTS FOR COTM RENEWAL BY MAY 31, 2009 WILL RESULT IN A REINSTATEMENT/LATE FEE 10 Public Government 20 Private Sector / Individual Client 30 Public / Private mix 40 Other funding source 7. LIABILITY INSURANCE: This section must be completed if renewing with COTM as ‘practising’ or ‘provisional’. As per The Occupational Therapists Regulation, Section 18: Every occupational therapist who provides clinical services shall obtain or be covered by, and maintain, liability insurance coverage to a minimum of $5,000,000.00. Indicate the type(s) of coverage you hold and complete the mandatory declaration: CAOT Insurance: expiry date _________________________ - Original insurance certificate required with renewal Other Insurance: expiry date _________________________ - Original insurance certificate required with renewal Employer Insurance: covered by HIROC or HED (please specify) _______________________________________________ Other Employer Insurance - Verification letter required with renewal The nature of my practice does not necessitate liability insurance MANDATORY DECLARATION: I understand that it is my responsibility to maintain professional liability insurance coverage for all relevant areas of O.T. practise. Initial here: 8. PROFESSIONAL REGISTRATION (As of June 1, 2009): Answer the question, and provide details if required Are you registered to practise occupational therapy in another province or country? Yes (provide details and proof) Regulatory Organization Province/State and Country No License/Registration # 9. REGISTRATION IN OTHER REGULATED PROFESSIONS (As of June 1, 2009): Answer the question, and provide details if required. Are you registered to practise in another profession in Manitoba or elsewhere? Yes (provide details and proof) No Check here if permanent registration certificate has already been submitted to COTM, then skip to Section 10 Regulatory Organization Province/State and Country License/Registration # 10. HISTORY and CONDUCT: Answer the following questions, and provide details if required. Do you have a physical or mental condition, disorder or addiction to alcohol or drugs that interferes with your ability to practise occupational therapy? Have you been refused registration by an O.T. regulatory organization since June 1, 2008? Have you had a finding of, or are you currently facing a proceeding for, professional misconduct, incompetency, incapacity or a similar issue in another jurisdiction? Have you had a finding of, or are you currently facing a proceeding for, professional misconduct, incompetency, incapacity or a similar issue in another profession in Manitoba or another jurisdiction? Have you been convicted of, or indicted for a criminal offence for which you have not been pardoned, or are you currently undergoing a criminal investigation? If you answered yes to any of the above, COTM will contact you with information on how to proceed. ALL COTM MEMBERS MUST COMPLETE EITHER SECTION 11 OR 12 Yes Yes Yes Yes Yes No No No No No 11. DECLARATION I hereby declare that, to the best of my knowledge, the information provided on this application is true, correct and complete in every respect. I agree to abide by The Occupational Therapists Act and Regulation and the By-laws and Code of Ethics of COTM and the Essential Competencies of Practice for Occupational Therapists in Canada. SIGNATURE_______________________________________ DATE________________________________ 12. RESIGNATION FROM COTM: Provide place and date of last employment as an OT Employer Address of Employer including postal code End Date I wish to cancel my registration with the College of Occupational Therapists of Manitoba, and declare that I will not be practising O.T. in Manitoba after June 1, 2009. I hereby declare that, to the best of my knowledge, the information provided on this application is true, correct and complete in every respect. I understand reinstatement of registration is required prior to resuming O.T. practice in Manitoba. FAILURE TO SUBMIT ALL DOCUMENTS FOR COTM RENEWAL BY MAY 31, 2009 WILL RESULT IN A REINSTATEMENT/LATE FEE SIGNATURE_______________________________________ DATE________________________________ 13. COTM / MSOT NOMINATIONS: Please answer the following questions: Would you consider serving on the Council of the College of Occupational Therapists of Manitoba? COTM is the regulatory organization for O.T.’s in Manitoba. Currently serving Yes No Would you consider serving on the Manitoba Society of Occupational Therapists Executive? MSOT represents and advocates on behalf of Manitoba’s occupational therapists. Currently serving Yes No 14. MSOT INFORMATION (to be completed by MSOT members only): Please answer the following questions: Would you be willing and able to provide O.T. services in a language other than English? Yes No Please specify language: ____________________ MSOTRF (Manitoba Society of Occupational Therapists Research Fund) Would you like to make a donation to the MSOTRF? Yes $____________ (A cheque made payable to COTF (Canadian Occupational Therapy Foundation) can be forwarded with your renewal.) Would you be willing to assist MSOTRF in reviewing grant applications? Yes No 15. MEMBERSHIP FEES: Check the category(ies) of membership that apply and submit fee(s) accordingly. College of Occupational Therapists of Manitoba Practising $350.00 Provisional $350.00 Non-Practising $140.00 Reinstatement (late fee) $50.00 Manitoba Society of Occupational Therapists Full member $75.00 Out of Province $45.00 Life Member No charge COTM TOTAL TOTAL ENCLOSED $ MSOT TOTAL $ $ Make cheque for the total amount (including MSOT fees) payable to: The College of Occupational Therapists of Manitoba (COTM) (post-dated cheques must be dated no later than June 1, 2009) FAILURE TO SUBMIT ALL DOCUMENTS FOR COTM RENEWAL BY MAY 31, 2009 WILL RESULT IN A REINSTATEMENT/LATE FEE