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Application And Renewal Guide

VIEWS: 10 PAGES: 4

									     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                           Complete Sections                       MSOT Renewal Status                         Complete Sections
  Renew as Practising                         1,2,3,4,5,6,7,8,9,10,11,13,15             Join as a Full Member                     1,2,3,13,14,15
  Renew as Provisional                        1,2,3,4,5,6,7,8,9,10,11,13,15             Join as Out of Province Member            1,2,3,13,14,15
  Renew as Non-Practising                     1,2,3,4,5,6a,8,9,10,11,13,15              Continue Life Membership                  1,2,3,13,14,15
  Cancel Registration                         1,2,5,12

2) DEMOGRAPHICS: Indicate necessary changes to demographic information below and complete blanks

Name:                                                                                                                        Member #

Full Address:




Postal Code:                                                    Preferred Email:

Home Phone:                                                                        Work Phone:

3) CONTACT PREFERENCES: Answer ‘yes’ or ‘no’ to the following questions.
a) For COTM members only:                   May COTM contact you via email?                       Yes      No
b) For MSOT members only:                   May MSOT contact you via email?                       Yes      No
c) For MSOT members only:                   Would you like to be on the MSOT mailing list?        Yes      No

4. EDUCATION UPDATES: Only complete if reporting new information. Submit a photocopy of any new degree(s) as evidence.
a) Designation:                 Certificate/Diploma                       Bachelors               Professional (course-based)Masters
                                Research (thesis-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.
                                                                                                                                        Total hours worked
            Worksite                                            Address Including Postal Code                   Dates of Employment      (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                            Scheduled hours

Primary                                                                                   □ Check here if same as in section 5

Secondary                                                                                 □ Check here if same as in section 5

Tertiary                                                                                  □ Check here if same as in section 5
[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                        Secondary site      □ yes □ no                         Tertiary site    □ yes □ no
Employment Category (indicate one for each employment)

Primary Employment        □□                       Secondary Employment          □□                       Tertiary Employment         □□
10 Permanent              20 Temporary                  30 Casual                  40 Self-Employed
Full/Part time Status (indicate one for each employment)

Primary Employment        □□                       Secondary Employment          □□                       Tertiary Employment         □□
10 Full time              20 Part time/Casual part time
Position (indicate one for each employment)

Primary Employment        □□                       Secondary Employment          □□                       Tertiary Employment         □□
10 Manager        20 Professional leader/ Coordinator             30 Direct Service Provider         40 Educator          50 Researcher       60 Other
Employer Type (indicate one employer type for each employment)

Primary Employment        □□□                      Secondary Employment          □□□                      Tertiary Employment         □□□
010   General Hospital                       060   Community Health Centre                     110   School or School Board
020   Rehabilitation Facility                070   Visiting Agency/ Business                   120   Assoc/Gov’t /Para-Government
030   Mental Health Hospital/Facility        080   Group Professional Practice/Clinic          130   Industry/Manufacturing & Commercial
040   Residential Care Facility              090   Solo Professional practice/Business         140   Other Employer type, not described
050   Assisted Living Residence              100   Post-Secondary Educational Institute
Area of Practice (indicate one for each employment)

Primary Employment        □□□                      Secondary Employment          □□□                      Tertiary Employment         □□□
010   Mental Health                      060       General Physical Health                     110   Service Administration
020   Neurological System                070       Vocational Rehabilitation                   120   Client Service Management
030   Musculoskeletal System             080       Palliative Care                             130   Medical/Legal related Client Service Management
040   Cardiovascular & Respiratory       090       Health Promotion & Wellness                 140   Teaching
050   Digestive/Metabolic/Endocrine      100       Other areas of Direct Service               150   Research                  160 Other Area of Practice
Geographical Area of Service Provision (indicate one for each employment)

Primary Employment        □□                       Secondary Employment          □□                       Tertiary Employment         □□
01    Winnipeg                          04     Eastman (North)              07     Parkland          10     Burntwood            13   Mixed
02    Brandon                           05     Eastman (South)              08     Nor-Man           11     Churchill            14   Out of Province
03    Assiniboine (excl. Brandon)       06     Central                      09     Interlake         12     Manitoba
Client Age Range

Primary Employment        □□                       Secondary Employment          □□                       Tertiary Employment         □□
10    Preschool age                     20     School age                   21     Mixed Pediatrics             30   Adults 18-64             40    Seniors 65+
41    Mixed Adults                      44     All Ages                     50     Other client age range       98   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                                          Initial here:
professional liability insurance coverage for all relevant areas of O.T. practise.

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)                   No
Regulatory Organization                                 Province/State and Country                                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?                                                                                           Yes       No

Have you been refused registration by an O.T. regulatory organization since June 1, 2008?                                   Yes       No
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?                                                                      Yes       No
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?                                    Yes       No
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?                                                                              Yes       No
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
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                     Manitoba Society of Occupational Therapists
   Practising                                $350.00                  Full member                              $75.00
   Provisional                               $350.00                  Out of Province                          $45.00
   Non-Practising                            $140.00                  Life Member                             No charge
   Reinstatement (late fee)                   $50.00


COTM TOTAL                             $                           MSOT TOTAL                           $

TOTAL ENCLOSED                         $
                                  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

								
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