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Stage 22

Application for Supervised Practice

PLEASE PRINT

Please complete all sections and attach relevant documents

Section A: Personal Details

Family name
Given name(s)
Any previous names (eg. prior to marriage)
Gender / Male  Female 
Date of birth / Day Month Year
Address for correspondence
Contact details – please provide private and business details, and write your email address clearly / Telephone Fax
e-mail
Telephone Fax
e-mail
Mobile:
Date of OTCStage 1 Assessment Letter
Qualifications / Date of Award
Awarding Institution / Country

Note:A short resume of your experience in the practice of occupational therapy MUST accompany your application. The resume should include dates where your experience was gained and the areas of experience.

Section B: Employer’s Details

Name of employing agency
Address of employing agency
Position for supervised practice audit
Commencement date of supervised practice audit / Day Month Year
Hours of work per week for period of supervised practice audit
Anticipated completion date for supervised practice audit / Day Month Year
Summary of services offered by employing agency
Note: Please attach copy of your Job Description 

Section C: Details of Supervisor(s)

Primary occupational therapist supervisor / Name
Position
Place of work
Contact details (telephone and email)
Registration no.
Qualification (name, institution and conferral date):
Secondary occupational therapist supervisor (if required) / Name
Position
Place of work
Contact details (telephone and email)
Registration no.
Qualification (name, institution and conferral date):
NOTE: Please include a curriculum vitae for each supervisor. If a third supervisor is required, please attach as a separate document, including all information above.

Section C: Practice Audit Details – if space is insufficient please attach separate document

Details of formal supervision with occupational therapy supervisor / Face to face  Frequency (specify)
Telephone  Frequency (specify)
Other (specify) 
Frequency (specify)
Supervised practice audit learning goals prepared in conjunction with supervisor(s) / Please complete and attached your learning goals, aims and how these are to be measured in the preferred format.
Description of the types of clients with whom you will work.
Description of the types of OT services you will provide eg. prescription of equipment, referral and liaison with community agencies, group work, work site visits, home visits, splinting etc.
Describe the range of skills and interventions to be undertaken eg. assessment using specific tools or protocols, planning individual programs, provision of services to individuals or groups, evaluation of care, report writing, communication with clients and others professionals.
Describe any other professional experiences that will be gained eg. specific quality activities, research, administrative duties etc
Detail the self-directed learning goals you will undertake to meet your learning goals. These would typically be activities you would undertake by yourself to gather information and learn about current or local issues of practice
Details of performance appraisal to be undertaken.
Signature of practitioner / Date
Signature of supervisor / Date

Checklist

Please ensure the following attachments are included with your application

Practitioner’s curriculum vitae.

Practitioner’s job description for supervised practice audit.

Supervisor’s curriculum vitae.

Learning goals in preferred format, identified appropriately, and signed by you and your supervisor.

Any additional documents related to the supervised practice audit.

Application fee.

Fees

The fee must accompany this application form and made payable to OTC in Australian dollars by one of the following methods:

  • A money order issued by Australia Post.
  • Credit card – form available on the website and should accompany this application.
  • A bank cheque drawn by an Australian bank.
  • A personal cheque drawn on an Australian bank account.
  • Foreign bank draft in Australian dollars and drawn on an Australian bank.
  • Direct debit as follows:

Account name:Occupational Therapy Council

Bank:Westpac

BSB:036 308

Account no.:28 2504

International Swift:WPACAU2S

Please ensure your name appears on the statement of the OTC, and you advise us via email that payment has been effected.

Please do not send your payment of fees in cash by post.

A receipt will be issued to acknowledge OTC has received your application and fee. The fee is not refundable.

Section D: Statement of Privacy

The Occupational TherapyCouncil (Australia & New Zealand) Ltd (OTC) is required to observe the provisions of the Commonwealth Privacy Amendment (Private Sector) Act 2000, which has effect from 21 December 2001 and sets out the requirements for the collection and use of personal information collected before and after that date.

As from 21 December 2001 each of the Application Forms used by the OTC is required to include a statement relating to the OTC’s privacy procedures. Each must be signed by the practitioner to give formal consent for the OTC to collect and hold personal information.

If consent is not provided, the OTC will not be able to process your application.

You must sign one of these consent forms for every application form you are submitting to the OTC.

Your privacy is respected by the OTC. Information collected by the OTC may be used for administering the assessment process and provided to OTC and the Overseas Qualifications Assessment Committee (OQAC) members, Australian Health Practitioner Regulation Agency, Occupational Therapists Registration Board of New Zealand and OT Australia (National and State Associations).

The OTC privacy procedures are set out in a Policy Statement which can be obtained from the OTC or its website If you have any privacy concerns or would like to verify information held about you please contact the OTC, PO Box 959, South Perth WA 6951

Consent to Collect Information:

Signature:...... Date:......

POST YOUR APPLICATION TO:

Occupational TherapyCouncil (Australia & New Zealand) Ltd

PO Box 959

South Perth WA 6951

Stage 2 – Application for Supervised PracticeRevised December 2012