Organization and Address for Directory Listing

REINSTATEMENT APPLICATION

While you should regularly notify RESNA when your contact information changes, recertification is a time to be sure the information listed in our database and on RESNA’s online directory of certified service providers is accurate so that RESNA mailings and updates are sent to the correct address.

Name:

Organization and address for directory listing:

Street:

City, State & Zip Code

Preferred mailing address:

Email: Fax:

Work Phone: ext: Alt phone:

Payment Form: (Indicate type of payment below and check renewal type)

If your certification lapsed, please complete this application and send documentation for completed continuing education.

One CEU is required for each year of certification. Documentation of an additional 0.25 CEUs is required for each three month period that follows after your term date. For example, if certification termed December 2012 and the reinstatement is submitted in June 2013, 2 CEUs are required with an additional .50 CEUs for the six month period following the term date. A total of 2.5 CEUs will be required.

Date certification termed:

Number of quarters (3 months) passed since termed certification:

Number of quarters x .25 CEUs: Total CEUs required for reinstatement:

Reinstatement Fee $250

Check Enclosed (make payable to RESNA)

Visa/MasterCard #:

Expiration Date: 3-Digit Security code on back of card:

Name on Card:

Billing Address of Card:

Signature: ______

Mail OR email application and maintain proof of submission until you receive your new certificate.

(Please do not do both to avoid duplicate charges)

Send application AND ALL CERTIFICATES OF ATTENDANCE to:

Name
First / Middle / Last / Maiden/Other
Employer
Employer Phone / Employment Dates

Describe below your responsibilities relating to assistive technology direct consumer-related services

(Document at least .25 FTE; 1 FTE = 35-40 hrs/week of direct-service work in AT (see page 1 above relevant experience) during the just-ending certification period. If you worked for multiple employers, photocopy this form and submit one for each employer.)

Percentage of time spent in AT direct consumer-related services with this employer = %

Signature

Please answer the following questions in order to address any issues that may be harmful to the public or inappropriate to the profession. A "yes" answer will not necessarily result in a denial of certification. However, please fully disclose any relevant information so that the RESNA Professional Standards Board can make an informed evaluation and decision.

Have you ever been convicted of, pled guilty or no contest to, been acquitted by reason of
mental disease or defect, entered into a diversion in lieu of prosecution, or had adjudication withheld on a felony charge in any legal jurisdiction? / Yes / No
Have you ever been convicted of, pled guilty or no contest to, been acquitted by reason of mental disease or defect, entered into a diversion in lieu of prosecution, or had adjudication withheld on a misdemeanor involving theft, fraud, bribery, corruption, perjury, embezzlement, solicitation, dishonesty, physical harm or threat of physical harm to the person or property of another or substance abuse in any legal jurisdiction? / Yes / No
Have you ever been subject to an adverse civil or administrative judgment for theft, fraud, corruption, embezzlement, solicitation, dishonesty, substance abuse, or other acts of moral turpitude (any offense that calls into questions the integrity or judgment of your actions)? / Yes / No
Are you currently or ever been subject to disciplinary action (i.e. sanctioned, reprimanded, suspended, or restricted) by any professional body, association, licensing authority, board or certifying association of which you were or are a member? / Yes / No
Have you ever been discharged from employment for theft, fraud, corruption, embezzlement, solicitation, dishonesty, substance abuse, or other acts of moral turpitude (any offense that calls into questions the integrity or judgment of your actions)? / Yes / No

Note: No applicant will be denied solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense will be considered.

I, the undersigned, certify the above and accompanying eligibility information is correct. I also acknowledge and accept the regulations of the RESNA Professional Standards Board and recognize this Board as the sole and only judge of my qualifications to receive and retain a certification issued on behalf of the Board and to have my name published in any list or directory in which certified, or de-certified, individuals are listed. I pledge to follow the RESNA Code of Ethics and RESNA Standards of Practice in my work with assistive technology.

I declare and affirm that the statements made in this certification application are complete and correct, understand that I may be subject to a random audit and a background check and that any false or misleading information may be cause for denial or disciplinary action.
To the best of my knowledge and belief I am in compliance with the RESNA Code of
Ethics and Standards of Practice.
Signature / Date

RESNA CEU requirement

20 hours of approved training in AT related continuing education.

10 hours must come from CEUs that are IACET, RESNA, or courses awarded CEUs by a university. The remaining 10 hours can be in the form of CEUs or contact hours.

RECORD OF AT-RELATED CONTINUING EDUCATION

Topic/Title / Sponsor / Credits
Earned / Dates

(Attach all certificates of attendance with this application)

(use only as needed for documenting RESNA Continuing Education in record)

Name of Attendee

Date of in-service

Presenter

Product Demonstrated

Number of minutes

Manufacturer in-service
Lecture
Demonstration
Product trial

Learning Objectives

1
2
3
4
Presenter Signature
Presenter’s employer
Presenter’s title
Date

Note: Please use this form for each in-service training event. You may document and use up to

3 contact hours of in-service training annually towards your recertification requirements.

Name
Last / First / Middle / Maiden/Other
Permanent
Address: / Street Address / Apt. Number
City/Town / State / Zip Code / Country
Home Phone / Fax / Cell Phone
Alternate
Mailing Address / Street Address / Apt. Number
City/Town / State / Zip Code / Country
E-mail Address:
Organization
Address for / Organization
Directory listing
Street Address / Apt. Number
City/Town / State / Zip Code / Country
Business Phone / Fax / Mobile

Highest Education Level Achieved

HS Diploma or GED

Associate - AA, AS

Bachelor - MA, MS

Masters -- MA, MS

Doctorate -- MD, PhD, EdD, ScD, DO, PTD, OTD, JD, etc

Other, specify

Are you a student presently?

Yes

Most Relevant Academic/Professional Training (Check all that apply)

Audiologist

Assistive Technologist

Attorney

Biomedical Engineer

Building Trades

Computer Science

Counseling

Electrical Engineer

Ergonomist

Educator, General Ed

Educator, Special Ed

Industrial Engineer

Mechanical Engineer

Mechanical Maintenance

Nurse

Occupational Therapist

OT Assistant

Orthotist

Physician

Physical Therapist

PT Assistant

Prosthetist

Psychologist

Rehabilitation Engineer

Social Worker

Speech & Language Pathologist

Technician

Other, specify

Professional Credentials/Licenses Held (Check all that apply)

ATP *

CPE

CRC

CRTS

LCSW

MD/DO

OTA

PTA

RET *

RRTS

SLP

SMS *

None

Other

Years worked in your professional area?

2 years or less

3 to 6 years

7 to 10 years

11 years or more

AT Practice Specialty (Check all that apply)

Cognition & Learning

Hearing

Vision

Communication

Seating, Positioning & Mobility

Transportation & Driving

Orthotics

Prosthetics

Computer Access & Applications

Environmental & Personal Aids for Daily Living

Architectural Accessibility & Universal Design

Employment & Workplace Modifications

Recreation, Leisure & Sports

Personal Robotics

Tele-rehab & Tele-monitoring

Other, specify

No AT practice specialty

What is your primary role in the AT field? (Check only one)

Service provider (e.g., evaluates users' abilities and needs; identifies and specifies AT and environmental solutions, manages service delivery processes, trains in the use of technology)
Technology Supplier (e.g., assesses user and devices; selects, orders, configures, customizes, designs, fabricates and sells commercial and non-commercial AT devices)
Manufacturer (e.g., designs, develops, tests, packages, distributes, resells, and markets commercial AT devices and software)
Educator of AT Professionals
Educator, e.g. pre-school, K-12, university, trade, etc.
Researcher
Resource Provider, e.g. information & referral, demonstration/loan/reuse programs, advocacy, funder, etc.
Other, specify

What other roles do you perform in the AT field? (Check all that apply)

What is your primary employment facility/setting (Check only one)

Academic institution (post-secondary education)

Acute care hospital

Health system or hospital-based outpatient facility or clinic

Industry/Manufacturer

Inpatient rehab facility

Patient's home/home care

Private outpatient office or private practice

Research center

School system

Skilled nursing facility/long term care facility

Municipal, state or federal government agency

Retail AT supplier

Community-based center, i.e. independent living center, Easter Seal center, ATA, etc.

Other, specify

Member Organizations Other than RESNA (Check all that apply)

AAA

ACM

AOTA

APTA

ASHA

ASME

ATA

BMES

HFES

IEEE

NRRTS

TASH

Other, specify

None

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