PEDIATRICS BOARD CERTIFICATION
Occupational Therapist
Table of Contents: ACTIVITY EVIDENCE FORMS
Guidelines:

Applicant must address criterion 11, as well as 5
additional criteria of their choosing by selecting
one (1) available option for each.

Please note that the term “ensures” can refer to
direct service delivery or the supervision or
teaching of others.

Reflections should demonstrate advancement in
professional development from initial certification.
Criterion 1: Knowledge: Lifespan & Conditions






AOTA Certification Application Reviewer
Expert Witness
Formal Learning (Min. 10 contact hours needed)
Independent Learning (Min. 10 contact hours needed)
Mentee (does not include supervisory relationship)
Publication – Reviewed by Expert(s)
Criterion 2: Knowledge: Evaluation






AOTA Certification Application Reviewer
Expert Witness
Formal Learning (Min. 10 contact hours needed)
Independent Learning (Min. 10 contact hours needed)
Mentee (does not include supervisory relationship)
Publication – Reviewed by Expert(s)
Criterion 3: Knowledge: Intervention






AOTA Certification Application Reviewer
Expert Witness
Formal Learning (Min. 10 contact hours needed)
Independent Learning (Min. 10 contact hours needed)
Mentee (does not include supervisory relationship)
Publication – Reviewed by Expert(s)
Criterion 4: Knowledge: Systems






AOTA Certification Application Reviewer
Expert Witness
Formal Learning (Min. 3 contact hours needed)
Independent Learning (Min. 3 contact hours needed)
Mentee (does not include supervisory relationship)
Publication – Reviewed by Expert(s)
Criterion 5: Evaluation: Uses Relevant
Evidence




Analysis of Recording or Observation
Case Study
Program Development
Research
Criterion 6: Evaluation: Prioritizes Needs




Case Study
Formal Specialized Consultation for Evaluation
Program Development
Research
Instructions:

Please complete 1 form for each criterion.

Combine completed forms in a single document
(e.g., Word or .PDF) and submit with the
completed Part 1 application to
https://www.filesdirect.com/AOTACertification

Please do not include unused forms.
Criterion 7: Intervention: Design &
Implementation







Analysis of Recording or Observation
Case Study, Client-Based
Case Study, Instructional
Formal Specialized Consultation for Intervention
Mentee (not supervisory relationship)
Program Development
Research
Criterion 8: Intervention: Wellness &
Prevention







Analysis of Recording or Observation
Case Study, Client-Based
Case Study, Instructional
Formal Specialized Consultation for Intervention
Mentee (not supervisory relationship)
Program Development
Research
Criterion 9: Outcomes



Formal Specialized Consultation for Outcomes
Program or Service Evaluation & Recommendation
Research
Criterion 10: Holistic Practice



Case Study, Holistic Practice
Program Development
Program or Service Evaluation & Recommendation
Criterion 11: Ethical Practice

The 3 ethical practice scenarios are found within
Part I of the application.
Criterion 12: Advocating for Change



Advocacy Efforts
Case Study, Advocacy
Volunteer Leadership
Criterion 13: Establishes Networks &
Resources

Case Study, Networking
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
AOTA CERTIFICATION APPLICATION REVIEWER
Back to Criteria
Criterion 1–Knowledge: Lifespan & Conditions
Demonstrates acquisition of current knowledge of the effects of the interaction between
lifespan issues and relevant conditions that impact occupational performance related to
pediatrics.
Guidelines

Complete required training for reviewers at the time of the review period, or once every 2
application cycles if reviewing more than once per year.

Serve as a reviewer for 3 AOTA Board Certification applications in pediatrics in the last 5 years.
1. Please verify activity information:
Date(s) of reviewer
training
Date(s) of application
review
Total number of
applications reviewed
2. Describe how the knowledge acquired from this activity helped you “demonstrate acquisition of current
knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact
occupational performance related to pediatrics.” How did the activity influence the way you practice, or
how did it affect your outcomes? (average word guideline–350)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
EXPERT WITNESS
Back to Criteria
Criterion 1–Knowledge: Lifespan & Conditions
Demonstrates acquisition of current knowledge of the effects of the interaction between
lifespan issues and relevant conditions that impact occupational performance related to
pediatrics.
Guidelines
 Serving as an expert witness in a civil or criminal legal case court or in arbitration.
 Providing expert testimony in official hearings at the local, state, or national level.
1. Describe the expertise which you were able to share relevant to pediatrics. (average word guideline–
200)
2. Describe how the knowledge acquired from this activity “demonstrates acquisition of current
knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact
occupational performance related to pediatrics.” How did the activity influence the way you practice, or
how did it affect your client outcomes? (average word guideline–200)
3. Submit verification of activity as a separate attachment. May include any 1 of the following:
 Transcript of the testimony.
 Notice of deposition.
 Letter from the attorney.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
FORMAL LEARNING
Back to Criteria
Criterion 1–Knowledge: Lifespan & Conditions
Demonstrates acquisition of current knowledge of the effects of the interaction between
lifespan issues and relevant conditions that impact occupational performance related to
pediatrics.
Guidelines
 Minimum of 10 contact hours required.
 Multiple activities may be used to meet the hour requirement for the criterion.
 Learning must have occurred in the past 5 years.
Please identify the type of activity in which you participated:
☐ AOTA CE: Participation in CE course from AOTA. Does not include courses from AOTA Approved
Providers. Completion of course will be verified by AOTA. Submission of additional documentation
beyond this form not required.
☐ Non-AOTA CE: Attending workshops, seminars, lectures, or professional conferences with formal
established objectives.
☐ Participation in post-professional academic coursework. Attach unofficial transcript.
1. Activity information.
Activity Title
Provider/Instructor
Activity Date(s)
No. of Contact Hours
2. Activity Learning Objectives. List up to 5.
A)
B)
C)
D)
E)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. Describe the relevance of the activity to your practice in pediatrics. (average word guideline–200)
4. Describe how the knowledge acquired from this activity “demonstrates acquisition of current
knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact
occupational performance related to pediatrics.” How did the activity influence the way you practice, or
how did it affect your client outcomes? (average word guideline–200)
5. Submit documentation that verifies completion of the activity, such as certificate of completion or
unofficial transcript. Not required for AOTA courses.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
INDEPENDENT LEARNING
Back to Criteria
Criterion 1–Knowledge: Lifespan & Conditions
Demonstrates acquisition of current knowledge of the effects of the interaction between
lifespan issues and relevant conditions that impact occupational performance related to
pediatrics.
Guidelines
 Minimum of 10 contact hours required.
 Multiple activities may be used to meet the hour requirement for the criterion.
 Learning must have occurred in the past 5 years.
Please identify the type of independent learning activity in which you participated:
☐ Independent reading of recent peer-reviewed, professional articles, or chapters in textbook not
associated with a formal learning course.
☐ Independent review of professional electronic resources (e.g., NIH, CDC, CanChild).
☐ AOTA Journal Club Toolkit (reading & discussion time). Must be AOTA member to access the kit.
☐ AOTA Critically Appraised Paper (CAP, includes submission to the AOTA Evidence Exchange).
1. Why did you choose this activity?
☐ Clinical reference for specific population, program, or individual
☐ Invited peer review of scholarly work or publication (print or online)
☐ Preparation for poster or presentation
☐ Preparation for academic lecture
☐ Literature review for research project
☐ Preparation for serving as a mentor
☐ Other, please specify:
2. Bibliography (APA Format) or list and objectives of select item(s) used for independent learning.
3. Date(s) of independent learning
4. Time spent engaged in independent learning.
 For reading, estimate 8–12 published pages/hour.
 For journal club, discussion time counts toward 10-hour requirement.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
5. Describe the relevance of the independent learning activity to your practice in pediatrics. (average
word guideline–200)
6. Describe how the knowledge acquired from this activity “demonstrates acquisition of current
knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact
occupational performance related to pediatrics.” How did the activity influence the way you practice, or
how did it affect your client outcomes? (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
MENTEE
Back to Criteria
Criterion 1–Knowledge: Lifespan & Conditions
Demonstrates acquisition of current knowledge of the effects of the interaction between
lifespan issues and relevant conditions that impact occupational performance related to
pediatrics.
Guidelines
 Must represent a minimum of 10 hours over a minimum of 2 months.
 Does not include supervisory relationships.
 Relationship must have occurred in the past 5 years.
 May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.
1. Dates of mentoring relationship
2. Approximately how many hours did this represent in total?
3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application.
List no more than 3.
A)
B)
C)
4.
Mentor
Position/Role of Mentor
Workplace of Mentor
Contact Information for
Mentor (email or phone number)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
5. State why the mentor was selected to help you meet the goals identified above relative to the
criterion. (average word guideline–50)
6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice
specific to your ability to “demonstrate acquisition of current knowledge of the effects of the
interaction between lifespan issues and relevant conditions that impact occupational performance
related to pediatrics.” (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
PUBLICATION – REVIEWED BY EXPERT(S)
Back to Criteria
Criterion 1–Knowledge: Lifespan & Conditions
Demonstrates acquisition of current knowledge of the effects of the interaction between
lifespan issues and relevant conditions that impact occupational performance related to
pediatrics.
Guidelines
 Examples of publication reviewed by experts include journals such as AJOT or OTJR.
 May include a chapter in an occupational therapy or related professional textbook, if chapter has
gone through peer review (a process in which subject matter experts, using a formal system and
defined guidelines, provide content guidance to an author and recommend publication, revision, or
rejection of a work).
1. Submit APA reference for the publication. For in-press publication, also include a verification letter or
e-mail identifying applicant and anticipated date of publication.
2. If applicant is not identified as first or second author, please describe your contribution/involvement in
the development of the publication. (average word guideline–200)
3. Provide a reflection indicating why this publication was chosen to represent “knowledge of the effects
of the interaction between lifespan issues and relevant conditions that impact occupational
performance related to pediatrics.” (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
AOTA CERTIFICATION APPLICATION REVIEWER
Back to Criteria
Criterion 2–Knowledge: Evaluation
Demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in
pediatrics.
Guidelines

Complete required training for reviewers at the time of the review period, or once every 2
application cycles if reviewing more than once per year.

Serve as a reviewer for 3 AOTA Board Certification applications in pediatrics in the last 5 years.
1. Please verify activity information:
Date(s) of reviewer
training
Date(s) of application
review
Total number of
applications reviewed
2. Describe how the knowledge acquired from this activity helped you “demonstrate acquisition of current
knowledge of relevant evidence specific to evaluation in pediatrics.” How did the activity influence the
way you practice, or how did it affect your outcomes? (average word guideline–350)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
EXPERT WITNESS
Back to Criteria
Criterion 2–Knowledge: Evaluation
Demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in
pediatrics.
Guidelines
 Serving as an expert witness in a civil or criminal legal case court or in arbitration.
 Providing expert testimony in official hearings at the local, state, or national level.
1. Describe the expertise which you were able to share relevant to pediatrics. (average word guideline–
200)
2. Describe how the knowledge acquired from this activity “demonstrates acquisition of current
knowledge of relevant evidence specific to evaluation in pediatrics.” How did the activity influence the
way you practice, or how did it affect your client outcomes? (average word guideline–200)
3. Submit verification of activity as a separate attachment. May include any 1 of the following:
 Transcript of the testimony.
 Notice of deposition.
 Letter from the attorney.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
FORMAL LEARNING
Back to Criteria
Criterion 2–Knowledge: Evaluation
Demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in
pediatrics.
Guidelines
 Minimum of 10 contact hours required.
 Multiple activities may be used to meet the hour requirement for the criterion.
 Learning must have occurred in the past 5 years.
Please identify the type of activity in which you participated:
☐ AOTA CE: Participation in CE course from AOTA. Does not include courses from AOTA Approved
Providers.Completion of course will be verified by AOTA. Submission of additional documentation
beyond this form not required.
☐ Non-AOTA CE: Attending workshops, seminars, lectures, or professional conferences with formal
established objectives.
☐ Participation in post-professional academic coursework. Attach unofficial transcript.
1. Activity information.
Activity Title
Provider/Instructor
Activity Date(s)
No. of Contact Hours
2. Activity Learning Objectives. List up to 5.
A)
B)
C)
D)
E)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. Describe the relevance of the activity to your practice in pediatrics. (average word guideline–200)
4. Describe how the knowledge acquired from this activity “demonstrates acquisition of current
knowledge of relevant evidence specific to evaluation in pediatrics.” How did the activity influence the
way you practice, or how did it affect your client outcomes? (average word guideline–200)
5. Submit documentation that verifies completion of the activity, such as certificate of completion or
unofficial transcript. Not required for AOTA courses.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
INDEPENDENT LEARNING
Back to Criteria
Criterion 2–Knowledge: Evaluation
Demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in
pediatrics.
Guidelines
 Minimum of 10 contact hours required.
 Multiple activities may be used to meet the hour requirement for the criterion.
 Learning must have occurred in the past 5 years.
Please identify the type of independent learning activity in which you participated:
☐ Independent reading of recent peer-reviewed, professional articles, or chapters in textbook not
associated with a formal learning course.
☐ Independent review of professional electronic resources (e.g., NIH, CDC, CanChild).
☐ AOTA Journal Club Toolkit (reading & discussion time). Must be AOTA member to access the kit.
☐ AOTA Critically Appraised Paper (CAP, includes submission to the AOTA Evidence Exchange).
1. Why did you choose this activity?
☐ Clinical reference for specific population, program, or individual
☐ Invited peer review of scholarly work or publication (print or online)
☐ Preparation for poster or presentation
☐ Preparation for academic lecture
☐ Literature review for research project
☐ Preparation for serving as a mentor
☐ Other, please specify:
2. Bibliography (APA Format) or list and objectives of select item(s) used for independent learning.
3. Date(s) of independent learning
4. Time spent engaged in independent learning.
 For reading, estimate 8–12 published pages/hour.
 For journal club, discussion time counts toward 10-hour requirement.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
5. Describe the relevance of the independent learning activity to your practice in pediatrics. (average
word guideline–200)
6. Describe how the knowledge acquired from this activity “demonstrates acquisition of current
knowledge of relevant evidence specific to evaluation in pediatrics.” How did the activity influence the
way you practice, or how did it affect your client outcomes? (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
MENTEE
Back to Criteria
Criterion 2–Knowledge: Evaluation
Demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in
pediatrics.
Guidelines
 Must represent a minimum of 10 hours over a minimum of 2 months.
 Does not include supervisory relationships.
 Relationship must have occurred in the past 5 years.
 May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.
1. Dates of mentoring relationship
2. Approximately how many hours did this represent in total?
3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application.
List no more than 3.
A)
B)
C)
4.
Mentor
Position/Role of Mentor
Workplace of Mentor
Contact Information for
Mentor (email or phone number)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
5. State why the mentor was selected to help you meet the goals identified above relative to the
criterion. (average word guideline–50)
6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice
specific to your ability to “demonstrate acquisition of current knowledge of relevant evidence specific
to evaluation in pediatrics.” (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
PUBLICATION – REVIEWED BY EXPERT(S)
Back to Criteria
Criterion 2–Knowledge: Evaluation
Demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in
pediatrics.
Guidelines
 Examples of peer-reviewed publication include journals such as AJOT or OTJR.
 May include a chapter in an occupational therapy or related professional textbook, if chapter has
gone through peer review (a process in which subject matter experts, using a formal system and
defined guidelines, provide content guidance to an author and recommend publication, revision, or
rejection of a work).
1. Submit APA reference for the publication. For in-press publication, also include a verification letter or
e-mail identifying applicant and anticipated date of publication.
2. If applicant is not identified as first or second author, please describe your contribution/involvement in
the development of the publication. (average word guideline–200)
3. Provide a reflection indicating why this publication was chosen to represent “acquisition of current
knowledge of relevant evidence specific to evaluation in pediatrics.” (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
AOTA CERTIFICATION APPLICATION REVIEWER
Back to Criteria
Criterion 3–Knowledge: Intervention
Demonstrates acquisition of current knowledge of relevant evidence specific to intervention
in pediatrics.
Guidelines

Complete required training for reviewers at the time of the review period, or once every 2
application cycles if reviewing more than once per year.

Serve as a reviewer for 3 AOTA Board Certification applications in pediatrics in the last 5 years.
1. Please verify activity information:
Date(s) of reviewer
training
Date(s) of application
review
Total number of
applications reviewed
2. Describe how the knowledge acquired from this activity helped you demonstrate “acquisition of current
knowledge of relevant evidence specific to intervention in pediatrics.” How did the activity influence the
way you practice, or how did it affect your outcomes? (average word guideline–350)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
EXPERT WITNESS
Back to Criteria
Criterion 3–Knowledge: Intervention
Demonstrates acquisition of current knowledge of relevant evidence specific to intervention
in pediatrics.
Guidelines
 Serving as an expert witness in a civil or criminal legal case court or in arbitration.
 Providing expert testimony in official hearings at the local, state, or national level.
1. Describe the expertise which you were able to share relevant to pediatrics. (average word guideline–
200)
2. Describe how the knowledge acquired from this activity helped you “demonstrate acquisition of current
knowledge of relevant evidence specific to intervention in pediatrics.” How did the activity influence the
way you practice, or how did it affect your client outcomes? (average word guideline–200)
3. Submit verification of activity as a separate attachment. May include any 1 of the following:
 Transcript of the testimony.
 Notice of deposition.
 Letter from the attorney.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
FORMAL LEARNING
Back to Criteria
Criterion 3–Knowledge: Intervention
Demonstrates acquisition of current knowledge of relevant evidence specific to intervention
in pediatrics.
Guidelines
 Minimum of 10 contact hours required.
 Multiple activities may be used to meet the hour requirement for the criterion.
 Learning must have occurred in the past 5 years.
Please identify the type of activity in which you participated:
☐ AOTA CE: Participation in CE course from AOTA. Does not include courses from AOTA Approved
Providers. Completion of course will be verified by AOTA. Submission of additional documentation
beyond this form not required.
☐ Non-AOTA CE: Attending workshops, seminars, lectures, or professional conferences with formal
established objectives.
☐ Participation in post-professional academic coursework. Attach unofficial transcript.
1. Activity information.
Activity Title
Provider/Instructor
Activity Date(s)
No. of Contact Hours
2. Activity Learning Objectives. List up to 5.
A)
B)
C)
D)
E)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. Describe the relevance of the activity to your practice in pediatrics. (average word guideline–200)
4. Describe how the knowledge acquired from this activity “demonstrates acquisition of current
knowledge of relevant evidence specific to intervention in pediatrics.” How did the activity influence the
way you practice, or how did it affect your client outcomes? (average word guideline–200)
5. Submit documentation that verifies completion of the activity, such as certificate of completion or
unofficial transcript. Not required for AOTA courses.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
INDEPENDENT LEARNING
Back to Criteria
Criterion 3–Knowledge: Intervention
Demonstrates acquisition of current knowledge of relevant evidence specific to intervention
in pediatrics.
Guidelines
 Minimum of 10 contact hours required.
 Multiple activities may be used to meet the hour requirement for the criterion.
 Learning must have occurred in the past 5 years.
Please identify the type of independent learning activity in which you participated:
☐ Independent reading of recent peer-reviewed, professional articles, or chapters in textbook not
associated with a formal learning course.
☐ Independent review of professional electronic resources (e.g., NIH, CDC, CanChild).
☐ AOTA Journal Club Toolkit (reading & discussion time). Must be AOTA member to access the kit.
☐ AOTA Critically Appraised Paper (CAP, includes submission to the AOTA Evidence Exchange).
1. Why did you choose this activity?
☐ Clinical reference for specific population, program, or individual
☐ Invited peer review of scholarly work or publication (print or online)
☐ Preparation for poster or presentation
☐ Preparation for academic lecture
☐ Literature review for research project
☐ Preparation for serving as a mentor
☐ Other, please specify:
2. Bibliography (APA Format) or list and objectives of select item(s) used for independent learning.
3. Date(s) of independent learning
4. Time spent engaged in independent learning.
 For reading, estimate 8–12 published pages/hour.
 For journal club, discussion time counts toward 10-hour requirement.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
5. Describe the relevance of the independent learning activity to your practice in pediatrics. (average
word guideline–200)
6. Describe how the knowledge acquired from this activity “demonstrates acquisition of current
knowledge of relevant evidence specific to intervention in pediatrics.” How did the activity influence the
way you practice, or how did it affect your client outcomes? (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
MENTEE
Back to Criteria
Criterion 3–Knowledge: Intervention
Demonstrates acquisition of current knowledge of relevant evidence specific to intervention
in pediatrics.
Guidelines
 Must represent a minimum of 10 hours over a minimum of 2 months.
 Does not include supervisory relationships.
 Relationship must have occurred in the past 5 years.
 May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.
1. Dates of mentoring relationship
2. Approximately how many hours did this represent in total?
3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application.
List no more than 3.
A)
B)
C)
4.
Mentor
Position/Role of Mentor
Workplace of Mentor
Contact Information for
Mentor (email or phone number)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
5. State why the mentor was selected to help you meet the goals identified above relative to the
criterion. (average word guideline–50)
6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice
specific to your ability to “demonstrate acquisition of current knowledge of relevant evidence specific
to intervention in pediatrics.” (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
PUBLICATION – REVIEWED BY EXPERT(S)
Back to Criteria
Criterion 3–Knowledge: Intervention
Demonstrates acquisition of current knowledge of relevant evidence specific to intervention
in pediatrics.
Guidelines
 Examples of publication reviewed by experts include journals such as AJOT or OTJR.
 May include a chapter in an occupational therapy or related professional textbook, if chapter has
gone through peer review (a process in which subject matter experts, using a formal system and
defined guidelines, provide content guidance to an author and recommend publication, revision, or
rejection of a work).
1. Submit APA reference for the publication. For in-press publication, also include a verification letter or
e-mail identifying applicant and anticipated date of publication.
2. If applicant is not identified as first or second author, please describe your contribution/involvement in
the development of the publication. (average word guideline–200)
3. Provide a reflection indicating why this publication was chosen to represent “demonstrates acquisition
of current knowledge of relevant evidence specific to intervention in pediatrics.” (average word
guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
AOTA CERTIFICATION APPLICATION REVIEWER
Back to Criteria
Criterion 4–Knowledge: Systems
Demonstrates acquisition of current knowledge of laws, regulations, payer sources, and
service delivery systems relevant to pediatrics.
Guidelines

Complete required training for reviewers at the time of the review period, or once every 2
application cycles if reviewing more than once per year.

Serve as a reviewer for 3 AOTA Board Certification applications in pediatrics in the last 5 years.
1. Please verify activity information:
Date(s) of reviewer
training
Date(s) of application
review
Total number of
applications reviewed
2. Describe how the knowledge acquired from this activity helped you “demonstrates acquisition of
current knowledge of laws, regulations, payer sources, and service delivery systems relevant to
pediatrics.” How did the activity influence the way you practice, or how did it affect your outcomes?
(average word guideline–350)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
EXPERT WITNESS
Back to Criteria
Criterion 4–Knowledge: Systems
Demonstrates acquisition of current knowledge of laws, regulations, payer sources, and
service delivery systems relevant to pediatrics.
Guidelines
 Serving as an expert witness in a civil or criminal legal case court or in arbitration.
 Providing expert testimony in official hearings at the local, state, or national level.
1. Describe the expertise which you were able to share relevant to pediatrics. (average word guideline–
200)
2. Describe how the knowledge acquired from this activity “demonstrates acquisition of current
knowledge of laws, regulations, payer sources, and service delivery systems relevant to pediatrics.”
How did the activity influence the way you practice, or how did it affect your client outcomes? (average
word guideline–200)
3. Submit verification of activity as a separate attachment. May include any 1 of the following:
 Transcript of the testimony.
 Notice of deposition.
 Letter from the attorney.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
FORMAL LEARNING
Back to Criteria
Criterion 4–Knowledge: Systems
Demonstrates acquisition of current knowledge of laws, regulations, payer sources, and
service delivery systems relevant to pediatrics.
Guidelines
 Minimum of 3 contact hours required.
 Multiple activities may be used to meet the hour requirement for the criterion.
 Learning must have occurred in the past 5 years.
Please identify the type of activity in which you participated:
☐ AOTA CE: Participation in CE course from AOTA. Does not include courses from AOTA Approved
Providers. Completion of course will be verified by AOTA. Submission of additional documentation
beyond this form not required.
☐ Non-AOTA CE: Attending workshops, seminars, lectures, or professional conferences with formal
established objectives.
☐ Participation in post-professional academic coursework. Attach unofficial transcript.
1. Activity information.
Activity Title
Provider/Instructor
Activity Date(s)
No. of Contact Hours
2. Activity Learning Objectives. List up to 5.
A)
B)
C)
D)
E)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. Describe the relevance of the activity to your practice in pediatrics. (average word guideline–200)
4. Describe how the knowledge acquired from this activity “demonstrates acquisition of current
knowledge of laws, regulations, payer sources, and service delivery systems relevant to pediatrics.”
How did the activity influence the way you practice, or how did it affect your client outcomes? (average
word guideline–200)
5. Submit documentation that verifies completion of the activity, such as certificate of completion or
unofficial transcript. Not required for AOTA courses.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
INDEPENDENT LEARNING
Back to Criteria
Criterion 4–Knowledge: Systems
Demonstrates acquisition of current knowledge of laws, regulations, payer sources, and
service delivery systems relevant to pediatrics.
Guidelines
 Minimum of 3 contact hours required.
 Multiple activities may be used to meet the hour requirement for the criterion.
 Learning must have occurred in the past 5 years.
Please identify the type of independent learning activity in which you participated:
☐ Independent reading of recent peer-reviewed, professional articles, or chapters in textbook not
associated with a formal learning course.
☐ Independent review of professional electronic resources (e.g., NIH, CDC, CanChild).
☐ AOTA Journal Club Toolkit (reading & discussion time). Must be AOTA member to access the kit.
☐ AOTA Critically Appraised Paper (CAP, includes submission to the AOTA Evidence Exchange).
1. Why did you choose this activity?
☐ Clinical reference for specific population, program, or individual
☐ Invited peer review of scholarly work or publication (print or online)
☐ Preparation for poster or presentation
☐ Preparation for academic lecture
☐ Literature review for research project
☐ Preparation for serving as a mentor
☐ Other, please specify:
2. Bibliography (APA Format) or list and objectives of select item(s) used for independent learning.
3. Date(s) of independent learning
4. Time spent engaged in independent learning.
 For reading, estimate 8–12 published pages/hour.
 For journal club, discussion time counts toward 3-hour requirement.
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
5. Describe the relevance of the independent learning activity to your practice in pediatrics. (average
word guideline–200)
6. Describe how the knowledge acquired from this activity “demonstrates acquisition of current
knowledge of laws, regulations, payer sources, and service delivery systems relevant to pediatrics.”
How did the activity influence the way you practice, or how did it affect your client outcomes? (average
word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
MENTEE
Back to Criteria
Criterion 4–Knowledge: Systems
Demonstrates acquisition of current knowledge of laws, regulations, payer sources, and
service delivery systems relevant to pediatrics.
Guidelines
 Must represent a minimum of 10 hours over a minimum of 2 months.
 Does not include supervisory relationships.
 Relationship must have occurred in the past 5 years.
 May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.
1. Dates of mentoring relationship
2. Approximately how many hours did this represent in total?
3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application.
List no more than 3.
A)
B)
C)
4.
Mentor
Position/Role of Mentor
Workplace of Mentor
Contact Information for
Mentor (email or phone number)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
5. State why the mentor was selected to help you meet the goals identified above relative to the
criterion. (average word guideline–50)
6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice
specific to your ability to “demonstrates acquisition of current knowledge of laws, regulations, payer
sources, and service delivery systems relevant to pediatrics.” (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
PUBLICATION – REVIEWED BY EXPERT(S)
Back to Criteria
Criterion 4–Knowledge: Systems
Demonstrates acquisition of current knowledge of laws, regulations, payer sources, and
service delivery systems relevant to pediatrics.
Guidelines
 Examples of publication reviewed by experts include journals such as AJOT or OTJR.
 May include a chapter in an occupational therapy or related professional textbook, if chapter has
gone through peer review (a process in which subject matter experts, using a formal system and
defined guidelines, provide content guidance to an author and recommend publication, revision, or
rejection of a work).
1. Submit APA reference for the publication. For in-press publication, also include a verification letter or
e-mail identifying applicant and anticipated date of publication.
2. If applicant is not identified as first or second author, please describe your contribution/involvement in
the development of the publication. (average word guideline–200)
3. Provide a reflection indicating why this publication was chosen to represent “demonstrates acquisition
of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to
pediatrics.” (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
ANALYSIS OF RECORDING OR OBSERVATION
Back to Criteria
Criterion 5—Evaluation: Uses Relevant Evidence
Uses relevant pediatrics evidence to ensure that an occupational profile with the client
(person, organization, population) is established and facilitates the assessment of the
client’s occupational performance through a variety of measures, including standardized
assessments, as appropriate.
Guidelines
 Submission of actual recording is not required for application; however, appropriate permissions
should be obtained by applicant whenever engaging a client in a recorded session.
1.
Age of Client
Client Diagnosis(es)
Setting for Evaluation
Date of Recording
2. Provide a brief summary of the recording contents and how it demonstrates your ability to “use
relevant pediatrics evidence to ensure that an occupational profile with the client (person,
organization, population) is established and facilitate the assessment of the client’s occupational
performance through a variety of measures, including standardized assessments, as appropriate.”
(average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. After reviewing this recording, describe the insights you gained, and reflect on how the analysis
experience validated or supported change in your practice related to evaluation. (average word
guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
CASE STUDY
Back to Criteria
Criterion 5—Evaluation: Uses Relevant Evidence
Uses relevant pediatrics evidence to ensure that an occupational profile with the client
(person, organization, population) is established and facilitates the assessment of the
client’s occupational performance through a variety of measures, including standardized
assessments, as appropriate.
Guidelines
 Client-based case study should not include any form of standard client documentation (e.g.,
evaluation summary, discharge plan) or identification of client name(s) or facility information.
1. Date(s) case study represents
2. Describe the client, client factors, and case contexts for the identified case. The context of the case
should be adequately communicated so that relevance and merit of the case to the criterion is easily
determined. (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. Articulate how this case demonstrates how you “use relevant pediatrics evidence to ensure that an
occupational profile with the client (person, organization, population) is established and facilitate the
assessment of the client’s occupational performance through a variety of measures, including
standardized assessments, as appropriate.” (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
FORMAL SPECIALIZED CONSULTATION FOR EVALUATION
Back to Criteria
Criterion 5—Evaluation: Uses Relevant Evidence
Uses relevant pediatrics evidence to ensure that an occupational profile with the client
(person, organization, population) is established and facilitates the assessment of the
client’s occupational performance through a variety of measures, including standardized
assessments, as appropriate.
Guidelines

This should not be confused with consultation that is part of the ongoing services provided in your
routine job duties. It is a request to address a particular issue at a particular site, either external or
internal.

Consultation may include (but is not limited to) developing or evaluating a program or service,
developing a strategy for long-term planning, establishing outcomes measures, incorporating
national guidelines into internal policies and procedures, assessing and addressing staff educational
needs, assessing and addressing resource needs, and validating program or service delivery with
current evidence.

Applicant must have had a minimum of 10 hours working with the site.
1.
Entity for Which Consultation
Was Completed
Date(s) of Consultation
No. of Hours Completed During
Consultation
2. Objectives for consultation. Objectives must have been met by time of application.
Please list no more than 3.
A)
B)
C)
3. Summarize the consultation results. (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Summarize how this professional development activity influenced your ability to “use relevant
pediatrics evidence to ensure that an occupational profile with the client (person, organization,
population) is established and facilitate the assessment of the client’s occupational performance
through a variety of measures, including standardized assessments, as appropriate.” (average word
guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
PROGRAM DEVELOPMENT
Back to Criteria
Criterion 5—Evaluation: Uses Relevant Evidence
Uses relevant pediatrics evidence to ensure that an occupational profile with the client
(person, organization, population) is established and facilitates the assessment of the
client’s occupational performance through a variety of measures, including standardized
assessments, as appropriate.
Guidelines
 Program development refers to the creation of a new program or development of an evolving
program.
1. Dates of program development
2. Briefly describe the program purpose, services offered, and clients served. (average word guideline–
250)
3. Describe how this program development activity, including description of resources used,
demonstrates your ability to “use relevant pediatrics evidence to ensure that an occupational profile
with the client (person, organization, population) is established and facilitate the assessment of the
client’s occupational performance through a variety of measures, including standardized assessments,
as appropriate.” (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
RESEARCH
Back to Criteria
Criterion 5—Evaluation: Uses Relevant Evidence
Uses relevant pediatrics evidence to ensure that an occupational profile with the client
(person, organization, population) is established and facilitates the assessment of the
client’s occupational performance through a variety of measures, including standardized
assessments, as appropriate.
What type of research was conducted? Please choose 1.
☐ Scientific inquiry–Qualitative, quantitative, or mixed-methods approach.
☐ Methodological research/instrument development–Scientific inquiry to establish
psychometric properties of (1) a new tool, (2) an existing tool with a new population, or (3) an
existing tool translated to a new language.
☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing
literature to answer a focused question.
1. Title of research conducted
2. Mechanism of dissemination:
☐ Publication
☐ Evidence-Based Practice
☐ Peer-reviewed presentation
☐ Project Web site
☐ Grant funding
☐ Dissertation/thesis
☐ Critically Appraised Topic (CAT, e.g., AOTA)
Citation:
3. Role of applicant in the research. (average word guideline–25)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Purpose and rationale of the research. (average word guideline–250)
5. Describe how this research demonstrates your ability to “use relevant pediatrics evidence to ensure
that an occupational profile with the client (person, organization, population) is established and
facilitate the assessment of the client’s occupational performance through a variety of measures,
including standardized assessments, as appropriate.” (average word guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
CASE STUDY
Back to Criteria
Criterion 6—Evaluation: Prioritizes Needs
Ensures prioritization of needs related to the client, context, and performance through the
synthesis and interpretation of assessment data and clinical observations (or supervision of
the same) in pediatrics.
Guidelines
 Client-based case study should not include any form of standard client documentation (e.g.,
evaluation summary, discharge plan) or identification of client name(s) or facility information.
1. Date(s) case study represents
2. Describe the client, client factors, and case contexts for the identified case. The context of the case
should be adequately communicated so that relevance and merit of the case to the criterion is easily
determined. (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. Articulate how this case demonstrates how you “ensure prioritization of needs related to the client,
context, and performance through the synthesis and interpretation of assessment data and clinical
observations (or supervision of the same) in pediatrics.” (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
FORMAL SPECIALIZED CONSULTATION FOR EVALUATION
Back to Criteria
Criterion 6—Evaluation: Prioritizes Needs
Ensures prioritization of needs related to the client, context, and performance through the
synthesis and interpretation of assessment data and clinical observations (or supervision of
the same) in pediatrics.
Guidelines

This should not be confused with consultation that is part of the ongoing services provided in your
routine job duties. It is a request to address a particular issue at a particular site, either external or
internal.

Consultation may include (but is not limited to) developing or evaluating a program or service,
developing a strategy for long-term planning, establishing outcomes measures, incorporating
national guidelines into internal policies and procedures, assessing and addressing staff educational
needs, assessing and addressing resource needs, and validating program or service delivery with
current evidence.

Applicant must have had a minimum of 10 hours working with the site.
1.
Entity for Which Consultation
Was Completed
Date(s) of Consultation
No. of Hours Completed During
Consultation
2. Objectives for consultation. Objectives must have been met by time of application.
Please list no more than 3.
A)
B)
C)
3. Summarize the consultation results. (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Summarize how this professional development activity influenced your ability to “ensure prioritization
of needs related to the client, context, and performance through the synthesis and interpretation of
assessment data and clinical observations (or supervision of the same) in pediatrics.” (average word
guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
PROGRAM DEVELOPMENT
Back to Criteria
Criterion 6—Evaluation: Prioritizes Needs
Ensures prioritization of needs related to the client, context, and performance through the
synthesis and interpretation of assessment data and clinical observations (or supervision of
the same) in pediatrics.
Guidelines
 Program development refers to the creation of a new program or development of an evolving
program.
1. Dates of program development
2. Briefly describe the program purpose, services offered, and clients served. (average word guideline–
250)
3. Describe how this program development activity, including description of resources used,
demonstrates your ability to “ensure prioritization of needs related to the client, context, and
performance through the synthesis and interpretation of assessment data and clinical observations (or
supervision of the same) in pediatrics.” (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
RESEARCH
Back to Criteria
Criterion 6—Evaluation: Prioritizes Needs
Ensures prioritization of needs related to the client, context, and performance through the
synthesis and interpretation of assessment data and clinical observations (or supervision of
the same) in pediatrics.
What type of research was conducted? Please choose 1.
☐ Scientific inquiry–Qualitative, quantitative, or mixed-methods approach.
☐ Methodological research/instrument development–Scientific inquiry to establish
psychometric properties of (1) a new tool, (2) an existing tool with a new population, or (3) an
existing tool translated to a new language.
☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing
literature to answer a focused question.
1. Title of research conducted
2. Mechanism of dissemination:
☐ Publication
☐ Evidence-Based Practice
☐ Peer-reviewed presentation
☐ Project Web site
☐ Grant funding
☐ Dissertation/thesis
☐ Critically Appraised Topic (CAT, e.g., AOTA)
Citation:
3. Role of applicant in the research. (average word guideline–25)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Purpose and rationale of the research. (average word guideline–250)
5. Describe how this research demonstrates your ability to “ensure prioritization of needs related to the
client, context, and performance through the synthesis and interpretation of assessment data and
clinical observations (or supervision of the same) in pediatrics.” (average word guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
ANALYSIS OF RECORDING OR OBSERVATION
Back to Criteria
Criterion 7—Intervention: Design & Implementation
Ensures the design and implementation of pediatrics interventions that are client-centered,
contextually relevant, and evidence-based to facilitate optimal occupational engagement.
Guidelines
 Submission of actual recording is not required for application; however, appropriate permissions
should be obtained by applicant whenever engaging a client in a recorded session.
 Observation should be consultative or instructive in nature and a minimum of 1 hour. It may occur
over multiple sessions.
1.
Age of Client
Client Diagnosis(es)
Setting for Evaluation
Date of Recording or
Observation
2. Provide a brief summary of the recording contents or observation and how it demonstrates your ability
to “ensure the design and implementation of pediatrics interventions that are client-centered,
contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average
word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. After reviewing this recording or observation, describe the insights you gained, and reflect on how the
analysis experience validated or supported change in your practice related to intervention – design and
implementation. (average word guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
CASE STUDY, CLIENT-BASED
Back to Criteria
Criterion 7—Intervention: Design & Implementation
Ensures the design and implementation of pediatrics interventions that are client-centered,
contextually relevant, and evidence-based to facilitate optimal occupational engagement.
Guidelines
 Client-based case study should not include any form of standard client documentation (e.g.,
evaluation summary, discharge plan) or identification of client name(s) or facility information.
1. Date(s) case study represents
2. Describe the client, client factors, and case contexts for the identified case. The context of the case
should be adequately communicated so that relevance and merit of the case to the criterion is easily
determined. (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. Articulate how this case demonstrates how you “ensure the design and implementation of pediatrics
interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal
occupational engagement.” (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
CASE STUDY, INSTRUCTIONAL
Back to Criteria
Criterion 7—Intervention: Design & Implementation
Ensures the design and implementation of pediatrics interventions that are client-centered,
contextually relevant, and evidence-based to facilitate optimal occupational engagement.
Guidelines
 Instructional case study refers to teaching that was provided to other practitioners that will be
delivering interventions in pediatrics. It should not include any form of standard client
documentation (e.g., evaluation summary, discharge plan) or identification of client name(s) or
facility information.
1. Date(s) case study represents
2. Describe the audience and context for the identified case. The context of the case should be
adequately communicated so that relevance and merit of the case to the criterion is easily determined.
(average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. Articulate how this case demonstrates how you “ensure the design and implementation of pediatrics
interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal
occupational engagement.” (average word guideline–350)
4. How was learning of the audience to whom you were instructing measured? (average word guideline–
150)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
FORMAL SPECIALIZED CONSULTATION FOR INTERVENTION
Back to Criteria
Criterion 7—Intervention: Design & Implementation
Ensures the design and implementation of pediatrics interventions that are client-centered,
contextually relevant, and evidence-based to facilitate optimal occupational engagement.
Guidelines

This should not be confused with consultation that is part of the ongoing services provided in your
routine job duties. It is a request to address a particular issue at a particular site, either external or
internal.

Consultation may include (but is not limited to) developing or evaluating a program or service,
developing a strategy for long-term planning, establishing outcomes measures, incorporating
national guidelines into internal policies and procedures, assessing and addressing staff educational
needs, assessing and addressing resource needs, and validating program or service delivery with
current evidence.

Applicant must have had a minimum of 10 hours working with the site.
1.
Entity for Which Consultation
Was Completed
Date(s) of Consultation
No. of Hours Completed During
Consultation
2. Objectives for consultation. Objectives must have been met by time of application.
Please list no more than 3.
A)
B)
C)
3. Summarize the consultation results. (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Summarize how this professional development activity influenced your ability to “ensure the design
and implementation of pediatrics interventions that are client-centered, contextually relevant, and
evidence-based to facilitate optimal occupational engagement.” (average word guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
MENTEE
Back to Criteria
Criterion 7—Intervention: Design & Implementation
Ensures the design and implementation of pediatrics interventions that are client-centered,
contextually relevant, and evidence-based to facilitate optimal occupational engagement.
Guidelines
 Must represent a minimum of 10 hours over a minimum of 2 months.
 Does not include supervisory relationships.
 Relationship must have occurred in the past 5 years.
 May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.
1. Dates of mentoring relationship
2. Approximately how many hours did this represent in total?
3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application.
List no more than 3.
A)
B)
C)
4.
Mentor
Position/Role of Mentor
Workplace of Mentor
Contact Information for
Mentor (email or phone number)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
5. State why the mentor was selected to help you meet the goals identified above relative to the
criterion. (average word guideline–50)
6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice
specific to your ability to “ensure the design and implementation of pediatrics interventions that are
client-centered, contextually relevant, and evidence-based to facilitate optimal occupational
engagement.” (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
PROGRAM DEVELOPMENT
Back to Criteria
Criterion 7—Intervention: Design & Implementation
Ensures the design and implementation of pediatrics interventions that are client-centered,
contextually relevant, and evidence-based to facilitate optimal occupational engagement.
Guidelines
 Program development refers to the creation of a new program or development of an evolving
program.
1. Dates of program development
2. Briefly describe the program purpose, services offered, and clients served. (average word guideline–
250)
3. Describe how this program development activity, including description of resources used,
demonstrates your ability to “ensure the design and implementation of pediatrics interventions that
are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational
engagement.” (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
RESEARCH
Back to Criteria
Criterion 7—Intervention: Design & Implementation
Ensures the design and implementation of pediatrics interventions that are client-centered,
contextually relevant, and evidence-based to facilitate optimal occupational engagement.
What type of research was conducted? Please choose 1.
☐ Scientific inquiry–Qualitative, quantitative, or mixed-methods approach.
☐ Methodological research/instrument development–Scientific inquiry to establish
psychometric properties of (1) a new tool, (2) an existing tool with a new population, or (3) an
existing tool translated to a new language.
☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing
literature to answer a focused question.
1. Title of research conducted
2. Mechanism of dissemination:
☐ Publication
☐ Evidence-Based Practice
☐ Peer-reviewed presentation
☐ Project Web site
☐ Grant funding
☐ Dissertation/thesis
☐ Critically Appraised Topic (CAT, e.g., AOTA)
Citation:
3. Role of applicant in the research. (average word guideline–25)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Purpose and rationale of the research. (average word guideline–250)
5. Describe how this research demonstrates your ability to “ensure the design and implementation of
pediatrics interventions that are client-centered, contextually relevant, and evidence-based to facilitate
optimal occupational engagement.” (average word guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
ANALYSIS OF RECORDING OR OBSERVATION
Back to Criteria
Criterion 8—Intervention: Wellness & Prevention
Provides or facilitates pediatrics interventions that incorporate wellness and prevention for
clients (persons, organizations, populations) to optimize present and future occupational
engagement.
Guidelines
 Submission of actual recording is not required for application; however, appropriate permissions
should be obtained by applicant whenever engaging a client in a recorded session.
 Observation should be consultative or instructive in nature and a minimum of 1 hour. It may occur
over multiple sessions.
1.
Age of Client
Client Diagnosis(es)
Setting for Evaluation
Date of Recording or
Observation
2. Provide a brief summary of the recording contents or observation and how it demonstrates your ability
to “provide or facilitate pediatrics interventions that incorporate wellness and prevention for clients
(persons, organizations, populations) to optimize present and future occupational engagement.”
(average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. After reviewing this recording or observation, describe the insights you gained, and reflect on how the
analysis experience validated or supported change in your practice related to intervention – wellness
and prevention. (average word guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
CASE STUDY, CLIENT-BASED
Back to Criteria
Criterion 8—Intervention: Wellness & Prevention
Provides or facilitates pediatrics interventions that incorporate wellness and prevention for
clients (persons, organizations, populations) to optimize present and future occupational
engagement.
Guidelines
 Client-based case study should not include any form of standard client documentation (e.g.,
evaluation summary, discharge plan) or identification of client name(s) or facility information.
1. Date(s) case study represents
2. Describe the client, client factors, and case contexts for the identified case. The context of the case
should be adequately communicated so that relevance and merit of the case to the criterion is easily
determined. (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. Articulate how this case demonstrates how you “provide or facilitate pediatrics interventions that
incorporate wellness and prevention for clients (persons, organizations, populations) to optimize
present and future occupational engagement.” (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
CASE STUDY, INSTRUCTIONAL
Back to Criteria
Criterion 8—Intervention: Wellness & Prevention
Provides or facilitates pediatrics interventions that incorporate wellness and prevention for
clients (persons, organizations, populations) to optimize present and future occupational
engagement.
Guidelines
 Instructional case study refers to teaching that was provided to other practitioners that will be
delivering interventions in pediatrics. It should not include any form of standard client
documentation (e.g., evaluation summary, discharge plan) or identification of client name(s) or
facility information.
1. Date(s) case study represents
2. Describe the audience and context for the identified case. The context of the case should be
adequately communicated so that relevance and merit of the case to the criterion is easily determined.
(average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. Articulate how this case demonstrates how you “provide or facilitate pediatrics interventions that
incorporate wellness and prevention for clients (persons, organizations, populations) to optimize
present and future occupational engagement.” (average word guideline–350)
4. How was learning of the audience to whom you were instructing measured? (average word guideline–
150)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
FORMAL SPECIALIZED CONSULTATION FOR INTERVENTION
Back to Criteria
Criterion 8—Intervention: Wellness & Prevention
Provides or facilitates pediatrics interventions that incorporate wellness and prevention for
clients (persons, organizations, populations) to optimize present and future occupational
engagement.
Guidelines

This should not be confused with consultation that is part of the ongoing services provided in your
routine job duties. It is a request to address a particular issue at a particular site, either external or
internal.

Consultation may include (but is not limited to) developing or evaluating a program or service,
developing a strategy for long-term planning, establishing outcomes measures, incorporating
national guidelines into internal policies and procedures, assessing and addressing staff educational
needs, assessing and addressing resource needs, and validating program or service delivery with
current evidence.

Applicant must have had a minimum of 10 hours working with the site.
1.
Entity for Which Consultation
Was Completed
Date(s) of Consultation
No. of Hours Completed During
Consultation
2. Objectives for consultation. Objectives must have been met by time of application.
Please list no more than 3.
D)
E)
F)
3. Summarize the consultation results. (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Summarize how this professional development activity influenced your ability to “provide or facilitate
pediatrics interventions that incorporate wellness and prevention for clients (persons, organizations,
populations) to optimize present and future occupational engagement.” (average word guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
MENTEE
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Criterion 8—Intervention: Wellness & Prevention
Provides or facilitates pediatrics interventions that incorporate wellness and prevention for
clients (persons, organizations, populations) to optimize present and future occupational
engagement.
Guidelines
 Must represent a minimum of 10 hours over a minimum of 2 months.
 Does not include supervisory relationships.
 Relationship must have occurred in the past 5 years.
 May be with a non-occupational therapy professional if appropriate to goal(s) of relationship.
1. Dates of mentoring relationship
2. Approximately how many hours did this represent in total?
3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application.
List no more than 3.
D)
E)
F)
4.
Mentor
Position/Role of Mentor
Workplace of Mentor
Contact Information for
Mentor (email or phone number)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
5. State why the mentor was selected to help you meet the goals identified above relative to the
criterion. (average word guideline–50)
6. Briefly describe how the knowledge acquired from this mentoring activity influenced your practice
specific to your ability to “provide or facilitate pediatrics interventions that incorporate wellness and
prevention for clients (persons, organizations, populations) to optimize present and future occupational
engagement.” (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
PROGRAM DEVELOPMENT
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Criterion 8—Intervention: Wellness & Prevention
Provides or facilitates pediatrics interventions that incorporate wellness and prevention for
clients (persons, organizations, populations) to optimize present and future occupational
engagement.
Guidelines
 Program development refers to the creation of a new program or development of an evolving
program.
1. Dates of program development
2. Briefly describe the program purpose, services offered, and clients served. (average word guideline–
250)
3. Describe how this program development activity, including description of resources used,
demonstrates your ability to “provide or facilitate pediatrics interventions that incorporate wellness and
prevention for clients (persons, organizations, populations) to optimize present and future occupational
engagement.” (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
RESEARCH
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Criterion 8—Intervention: Wellness & Prevention
Provides or facilitates pediatrics interventions that incorporate wellness and prevention for
clients (persons, organizations, populations) to optimize present and future occupational
engagement.
What type of research was conducted? Please choose 1.
☐ Scientific inquiry–Qualitative, quantitative, or mixed-methods approach.
☐ Methodological research/instrument development–Scientific inquiry to establish
psychometric properties of (1) a new tool, (2) an existing tool with a new population, or (3) an
existing tool translated to a new language.
☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing
literature to answer a focused question.
1. Title of research conducted
2. Mechanism of dissemination:
☐ Publication
☐ Evidence-Based Practice
☐ Peer-reviewed presentation
☐ Project Web site
☐ Grant funding
☐ Dissertation/thesis
☐ Critically Appraised Topic (CAT, e.g., AOTA)
Citation:
3. Role of applicant in the research. (average word guideline–25)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Purpose and rationale of the research. (average word guideline–250)
5. Describe how this research demonstrates your ability to “provide or facilitate pediatrics interventions
that incorporate wellness and prevention for clients (persons, organizations, populations) to optimize
present and future occupational engagement.” (average word guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
FORMAL SPECIALIZED CONSULTATION FOR OUTCOMES
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Criterion 9—Outcomes
Ensures that services that are delivered, either for caseload or programs, are validated and
that changes are made as appropriate to maximize outcomes related to pediatrics.
Guidelines

This should not be confused with consultation that is part of the ongoing services provided in your
routine job duties but is a request to address a particular issue at a particular site, either external
or internal.

Consultation may include (but is not limited to) developing or evaluating a program or service,
developing a strategy for long-term planning, establishing outcomes measures, incorporating
national guidelines into internal policies and procedures, assessing and addressing staff educational
needs, assessing and addressing resource needs, and validating program or service delivery with
current evidence.

Applicant must have had a minimum of 10 hours working with the site.
1.
Entity for Which Consultation
Was Completed
Date(s) of Consultation
No. of Hours Completed During
Consultation
2. Objectives for consultation. Objectives must have been met by time of application.
Please list no more than 3.
A)
B)
C)
3. Summarize the consultation results. (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Summarize how this professional development activity influenced your ability to “ensure that services
that are delivered, either for caseload or programs, are validated and that changes are made as
appropriate to maximize outcomes related to pediatrics.” (average word guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
PROGRAM or SERVICE EVALUATION & RECOMMENDATION
Back to Criteria
Criterion 9—Outcomes
Ensures that services that are delivered, either for caseload or programs, are validated and
that changes are made as appropriate to maximize outcomes related to pediatrics.
Guidelines
 Refers to evaluation of an activity implemented in a program, department, facility, or organization.
 Should not include any form of standard client documentation (e.g., evaluation summary, discharge
plan) or identification of client name(s) or facility information.
1.
Type of Program or Service Being
Evaluated
Date(s) of Evaluation
2. Describe the caseload or program being evaluated. The context should be adequately communicated
so that relevance and merit to the criterion is easily determined. (average word guideline–300)
3. Identify methods or tools used for the program or service evaluation. (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Summarize evaluation findings. (average word guideline–200)
5. What actions were taken in response to the findings? (average word guideline–300)
6. Summarize how this program evaluation demonstrates your ability to “ensure that services that are
delivered, either for caseload or programs, are validated and that changes are made as appropriate to
maximize outcomes related to pediatrics.” (average word guideline–300)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
RESEARCH
Back to Criteria
Criterion 9—Outcomes
Ensures that services that are delivered, either for caseload or programs, are validated and
that changes are made as appropriate to maximize outcomes related to pediatrics.
What type of research was conducted? Please choose 1.
☐ Scientific inquiry–Qualitative, quantitative, or mixed-methods approach.
☐ Methodological research/instrument development–Scientific inquiry to establish
psychometric properties of (1) a new tool, (2) an existing tool with a new population, or (3) an
existing tool translated to a new language.
☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing
literature to answer a focused question.
1. Title of research conducted
2. Mechanism of dissemination:
☐ Publication
☐ Evidence-Based Practice
☐ Peer-reviewed presentation
☐ Project Web site
☐ Grant funding
☐ Dissertation/thesis
☐ Critically Appraised Topic (CAT, e.g., AOTA)
Citation:
3. Role of applicant in the research. (average word guideline–25)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Purpose and rationale of the research. (average word guideline–250)
5. Describe how this research demonstrates your ability to “ensure that services that are delivered, either
for caseload or programs, are validated and that changes are made as appropriate to maximize
outcomes related to pediatrics.” (average word guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
CASE STUDY, HOLISTIC PRACTICE
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Criterion 10— Holistic Practice
Ensures that client’s needs, including physical, social, and emotional well-being, are
addressed holistically to maximize occupational performance in pediatrics.
Guidelines
 Client-based case study should not include any form of standard client documentation (e.g.,
evaluation summary, discharge plan) or identification of client name(s) or facility information.
 Client refers to a person, organization, or population.
1. Identify the primary reason for referral:
☐ Physical
☐ Social
☐ Emotional
2. Date(s) case study represents.
3. Describe the client, client factors, and case contexts for the identified case. (average word guideline–
300)
4. Describe other client needs (physical, social, emotional) you identified over the course of involvement
and how you addressed these needs. (average word guideline–100)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
5. Articulate how this case demonstrates your ability to “ensure that client’s needs, including physical,
social, and emotional well-being, are addressed holistically to maximize occupational performance in
pediatrics.” (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
PROGRAM DEVELOPMENT
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Criterion 10— Holistic Practice
Ensures that client’s needs, including physical, social, and emotional well-being, are
addressed holistically to maximize occupational performance in pediatrics.
Guidelines
 Program development refers to the creation of a new program or development of an evolving
program.
1. Dates of program development
2. Briefly describe the program purpose, services offered, and clients served. (average word guideline–
250)
3. Describe how this program development activity, including description of resources used,
demonstrates your ability to “ensure that client’s needs, including physical, social, and emotional wellbeing, are addressed holistically to maximize occupational performance in pediatrics.” (average word
guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
PROGRAM OR SERVICE EVALUATION & RECCOMMENDATION
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Criterion 10— Holistic Practice
Ensures that client’s needs, including physical, social, and emotional well-being, are
addressed holistically to maximize occupational performance in pediatrics.
Guidelines
 Refers to evaluation of an activity implemented in a program, department, facility, or organization.
 Should not include any form of standard client documentation (e.g., evaluation summary, discharge
plan) or identification of client name(s) or facility information.
1.
Type of Program or Service Being
Evaluated
Date(s) of Evaluation
2. Describe the caseload or program being evaluated. The context should be adequately communicated
so that relevance and merit to the criterion is easily determined. (average word guideline–300)
3. Identify methods or tools used for the program/service evaluation. (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Summarize evaluation findings. (average word guideline–200)
5. What actions were taken in response to the findings? (average word guideline–300)
6. Summarize how this program evaluation demonstrates your ability to “ensure that client’s needs,
including physical, social, and emotional well-being, are addressed holistically to maximize
occupational performance in pediatrics.” (average word guideline–300)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
ADVOCACY EFFORTS
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Criterion 12— Advocating for Change
Advances access to services or influences policies or programs that promote the health and
occupational engagement of clients (persons, organizations, populations) in the area of
pediatrics.
Guidelines
 Active involvement in or facilitation of advocacy activities at the local, regional, state, or national
level for the purpose of influencing decision-makers about policy, procedures, services,
reimbursement, or occupational justice issues.
 Merely serving as a participant does not constitute advocacy efforts.
 Minimum of 10 hours over at least 2 months.
Type of advocacy activity: (check all that apply)
☐ Development and dissemination of advocacy materials (e.g., letters, brochures, Web sites,
podcasts)
☐ Lobbying to/education for policy-makers
☐ Organizer of community event (e.g., fundraising, health fair)
☐ Subject expert in media interview (e.g., radio, television news, newspaper)
☐ Presentation to stakeholder
☐ Other
1.
Description of Activity
Target Audience
Date(s)
2. Applicant’s objectives for advocating for change. List no more than 3.
A)
B)
C)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
No. of Hours
Involved
3. Discuss the results, outcomes, or progress toward change affected by this advocacy effort that
demonstrates how you “advance access to services or influence policies or programs that promote the
health and occupational engagement of clients (persons, organizations, populations) in the area of
pediatrics.” (average word guideline–350)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
CASE STUDY, ADVOCACY
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Criterion 12— Advocating for Change
Advances access to services or influences policies or programs that promote the health and
occupational engagement of clients (persons, organizations, populations) in the area of
pediatrics.
Guidelines
 Efforts toward change that influence access to services, policy, or programs that promote the
health and occupational engagement of clients.
 This should not be confused with routine job duties associated with expected occupational therapy
service delivery. For example, submitting letters of necessity for equipment would not meet intent.
1. Describe the client (person, organization, population) or program and the context as it applies to an
identified need for change. (average word guideline–100)
2. Summarize your efforts to influence change. (average word guideline–200)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
3. Describe the change outcomes or progress toward change as a result of your efforts. (average word
guideline–200)
4. Articulate how this case demonstrates your ability to “advance access to services or influence policies
or programs that promote the health and occupational engagement of clients (persons, organizations,
populations) in the area of pediatrics.” (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
VOLUNTEER LEADERSHIP
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Criterion 12— Advocating for Change
Advances access to services or influences policies or programs that promote the health and
occupational engagement of clients (persons, organizations, populations) in the area of
pediatrics.
Guidelines
 Service with a local, state, national, or international agency or organization that has relevance to
the criterion.
 Minimum of 25 hours for at least 1 year.
1. Name of organization
2. Dates of service
3. Approximate number of hours of service
4. Identification of the volunteer leadership role served (must be leadership in nature, e.g., officer, chair,
committee member, board member)
5. Describe how this leadership activity helped you “advance access to services or influence policies or
programs that promote the health and occupational engagement of clients (persons, organizations,
populations) in the area of pediatrics.” (average word guideline–400)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
NETWORKING CASE STUDY
Table of Contents
Criterion 13– Establishes Networks & Resources
Establishes or contributes to the advancement of pediatrics networks and collaborates with
team members, referral sources, or stakeholders to support clients’ occupational engagement.
Guidelines
 The networking case study should reflect an understanding of the system in which you work and an
ability to establish networks and resources outside of your routine work group and referral pathways.
 The networking case study should not include any form of standard client documentation (e.g.,
evaluation summary, discharge plan).
1. Date(s) case study represents.
2. Identify the issue(s) that interfered with the occupational engagement for one or more clients (person,
organization, population). (average word guideline–100)
3. Identify the key networks or resources you established or accessed to address the issue. (average
word guideline–100)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
4. Articulate how this case demonstrates your ability to “establish or contribute to the advancement of
pediatrics networks and collaborate with team members, referral sources, or stakeholders to support
clients’ occupational engagement.” (average word guideline–500)
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.