AOTA BOARD CERTIFICATION RENEWAL
IN PEDIATRICS
Occupational Therapist
Candidate Renewal Application
American Occupational Therapy Association
4720 Montgomery Lane
Bethesda, MD 20814-5320
800-SAY-AOTA, ext. 2838 (Members)
301-652-AOTA, ext. 2838 (Nonmembers and Local)
[email protected]
http://www.aota.org/certification
CONTENTS
Background and Information
Purpose
Benefits of Certification
Authority
Occupational Therapy Code of Ethics
Eligibility
Submission Deadlines and Review Period
Application Fee
Application
Part A. Applicant Information
Employment/Volunteer Verification Form
Part B. Reflective Portfolio
Identification of activity choices to provide evidence for criteria
Ethical practice—1 of 3
Ethical practice—2 of 3
Ethical practice—3 of 3
Part C. Goal Status and Reflection
Part D. Self-Assessment
Part E. Professional Development Plan
Completion Guidelines and Attestation
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
2
BACKGROUND AND INFORMATION
AOTA Board Certification RENEWAL
In PEDIATRICS
Purpose
Through its Board Certification programs, the American Occupational Therapy Association
(AOTA) provides formal recognition for practitioners who have engaged in a voluntary
process of ongoing professional development and who are able to translate that
development into improved client outcomes.
The AOTA certification process recognizes applicants who have carefully designed and
systematically completed professional development activities that facilitate achievement of
the criteria delineated for a specialized practitioner in the certification area.
Renewal of AOTA Board Certification is based on peer-review that includes (1)
demonstration of relevant experience, (2) a reflective portfolio, and (3) ongoing professional
development. The objectives of Board Certification renewal are to recognize and
acknowledge increased specialization and/or advanced practice in a certification area and
to:
1. Create a community of practitioners who share a commitment to continuing
competence and the development of the profession.
2. Facilitate and respond to the future development of best practice, education, and
research in occupational therapy.
3. Assist consumers and others in the health care community in identifying practitioners
with expertise in recognized areas of practice.
Benefits of Certification Renewal

Clinicians--Personal accomplishment, professional recognition, career advancement

Administrators--Career laddering, The Joint Commission and other stakeholders,
marketing

Faculty--Models the importance of ongoing professional development and reinforces
the critical examination of clinical practice, which can be extended to support
learning opportunities for students.
Authority
Pediatrics Board Certification is awarded by AOTA and is
 A private program
 Not awarded or required by federal or state governments
 Not required as part of the minimum qualifications to work as an occupational therapist
 Voluntary.
Pediatrics Board Certification is awarded to individuals who have demonstrated the capacity
for meeting identified criteria that reflect advanced occupational therapy practice in the area
of pediatrics through a peer-reviewed reflective portfolio process.
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
3
Administration of the program is by the AOTA Board for Advanced and Specialty
Certification (BASC) under the auspices of the AOTA Commission on Continuing Competence
and Professional Development (CCCPD).
Occupational Therapy Code of Ethics
Articulated within Principle 1 of the Occupational Therapy Code of Ethics is the expectation
that occupational therapy practitioners shall maintain competency and provide services that
are within their scope of practice. It also reminds us that each practitioner is responsible for
maintaining high standards and continuing competence in practice, education, and research
(AOTA, 2015).
The Board Certification program embodies these ethical principles by offering applicants a
way to document and reflect on professional development in which they have engaged, as
well as determine future learning needs and plan subsequent professional development
activities that will enhance their practice.
Reference
American Occupational Therapy Association. (2015). Occupational therapy code of ethics
(2015). American Journal of Occupational Therapy, 69(Suppl. 3), 6913410030.
http://dx.doi.org/10.5014/ajot.2015.696S03
Eligibility
 Initial certification in Pediatrics by AOTA
 Able to meet regulatory requirements to practice in the state(s) in which they provide
service.
 Minimum of 3000 hours in the certification area in the past 5 calendar years.1, 2, 3
 Verification of employment.
Must be as an occupational therapy practitioner at the level for which certification is
sought. For example, applicants seeking certification at the occupational therapist level
must have accumulated the necessary hours as an occupational therapist, not as an
occupational therapy assistant or other type of professional.
1
Hours may include roles in any capacity (e.g., clinician, faculty, administrator) as long as
they are relevant to the certification area and occupational therapy.
2
3
Service delivery may be paid or voluntary.
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
4
Submission Deadlines and Review Period
 Renewal applications will be accepted by the second Wednesday of September and
March of each year for all certifications. Eligible candidates will be notified about
upcoming deadlines by e-mail.
 Applications are peer-reviewed and processed over a 4-month period following the
application deadline. Review for September applications occurs October to January;
review for March applications occurs April to July.
 Applications are confirmed as Approved, Denied, or Clarification Needed. Applications that
require minimal clarification will be processed with no additional fee. Applications that
require clarification significant enough that the content of the application may be altered
will be charged an additional $100 processing fee.
Renewal Application Fee
Board Certification: $475.00 (nonrefundable)
Applicants must be AOTA members at the time of application and at the time certification is
granted. Membership is not required to maintain certification once granted, except at the
time of renewal.
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
5
PEDIATRICS RENEWAL APPLICATION
Part A. Applicant Information
Please complete the following information.
APPLICANT INFORMATION
AOTA Member ID
Name (Last, First, MI)
Credentials
Primary E-mail
Home Address
City
State
Home Phone
Work Phone
ZIP
CURRENT LICENSURE If not required by state, please mark “n/a.”
State(s) Licensed
License Number(s)
Expiration Date
If more than 4, please list additional here.
OTHER CERTIFICATIONS
Certifying Agency
Credential
Awarded, If
Any
Date of
Initial
Certification
Certification
Expiration
Date
If more than 4, please list additional here.
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
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PROFESSIONAL MEMBERSHIPS If more than 4, combine multiples in 1 box.
Organization Name
Dates of
Membership
Organization’s Focus/Mission
If more than 4, please list additional here.
EMPLOYMENT--CURRENT Primary
Employer Name
Dates with Employer
Current Position or Title
Employer Address
City
Type of Setting
☐ Academic Institution
☐ Community-Based Setting
☐ Government--Federal
☐ Government--Local, State
☐ Home Health Agency
☐ Long-term Care Facility/SNF
☐ Hospital Setting
State
☐
☐
☐
☐
☐
☐
☐
ZIP
Military
Non-profit Agency
Private Industry
Private Practice
Rehab Facility
School System
Other (please specify): ____________________
Clients Served
Please identify the populations served at this setting on which this application is based.
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
7
EMPLOYMENT – CURRENT Secondary, if applicable
Employer Name
Dates With Employer
Current Position or Title
Employer Address
City
Type of Setting
☐ Academic Institution
☐ Community-Based Setting
☐ Government--Federal
☐ Government--Local, State
☐ Home Health Agency
☐ Long-term Care Facility/SNF
☐ Hospital Setting
State
☐
☐
☐
☐
☐
☐
☐
ZIP
Military
Non-profit Agency
Private Industry
Private Practice
Rehab Facility
School System
Other (please specify):
Clients Served
Please identify the populations served at this setting on which this application is based.
EMPLOYMENT--PAST
If there are employers in the past 5 years other than those listed above, please identify
below.
Dates With
Previous Employer Name
State
Previous Employer
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
8
VERIFICATION OF EMPLOYMENT/VOLUNTEER SERVICE
An employment/volunteer verification form is required to provide third-party verification of
the required hours (see next page). Applicants may submit as many forms as needed to
verify the required hours, and duplication of the form is acceptable if needed for more than
one employer.
Instructions for submitting Verification Form: Print the form and have
employers(s) complete. Include the form as a scanned document as the first page(s)
of either the application or evidence file.
Tracking Hours--It is up to applicants how to track the specifics of their service delivery.
We ask only for the employment verification form(s) to be submitted, so be sure that
whoever is verifying the information feels comfortable and ethical with whatever tracking
system is used.
Self-Employed--Because private practice takes on many different forms, applicants have
varying ways in which to handle employment verification. Examples of who might verify the
form include
 Administrator for a company/organization that contracted with the private practitioner
for services
 Referral source
 Business partner or co-owner
 Accountant for the practice.
If none of the options listed above fit an applicant’s situation, and the applicant has an
alternative source for verification to use, the applicant may forward that information for
review and approval to [email protected] prior to submitting an application.
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
9
AOTA BOARD CERTIFICATION
Employment/Volunteer Verification Form - RENEWAL
Employer:

You are being asked to verify employment or delivery of occupational therapy services for someone
who is applying for renewal of Board Certification by the American Occupational Therapy Association
(AOTA).

Please complete all sections of this form and return it to the applicant so that it can be included in
his or her application portfolio.

If you have questions, please contact AOTA at [email protected] or (301) 652-6611, ext. 2838. Thank
you for your assistance!
Applicant:

Submit only as many forms as needed to verify the required hours of occupational therapy experience.
Duplication of the form is acceptable if more than one employer is completing the form.

The form must be submitted as the first page(s) of the electronic portfolio of scanned evidence (e.g.,
portable document format [PDF]) that is submitted in support of the application. The application will
not be accepted if materials are submitted separately.
Applicant Name
Certification Sought
☐ Gerontology
☐ Mental Health
☐ Pediatrics
☐ Physical Rehabilitation
Name of Facility/Company/Organization
City
Applicant Start Date
State
Applicant End Date
Employment
Type:
☐
☐
☐
☐
Full-time
Part-time
Contract/PRN
Volunteer
Verification
This employment/volunteer service represents ________ hours within the past 5 calendar years toward
the 3,000 hours required as an occupational therapist in the certification area. This may include roles in
any capacity (service delivery, administration, teaching, research) as long as they are relevant to the
certification area and occupational therapy.
Name of Person Completing Form (please print)
Signature of person completing form
Job Title
Phone Number
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
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PEDIATRICS RENEWAL APPLICATION
PART B. Reflective Portfolio
AOTA certification programs focus on continuing competence, or the building of capacity to
meet identified criteria. Continuing competence is a component of ongoing professional
development or lifelong learning. Applicants are expected to engage in a process of selfappraisal relative to the identified criteria. This involves the deliberate selection of the best
supporting evidence that demonstrates applicant’s potential for meeting identified criteria
and answers the question, What evidence would best indicate that I meet the criteria for
specialized practice?
Submit only 1 activity for each criterion. Complete the required professional development
activity form for each activity being submitted.
Items to Submit
A single file (preferably PDF) should include:
1. This Part 1 application form, which also includes Criterion 14, Ethical Practice
2. Employment verification form
3. Activity Forms for 5 additional criteria
4. Any additional evidence as required on the Activity Forms.
Guidelines:

For each of the 5 of the 13 criteria selected, choose only 1 of the available options to
submit as part of the application.

Activities must have occurred within the 5 years since initial certification and prior to
submitting the application.

An activity may not be used to meet more than 1 criterion. For example, a formal
learning activity engaged in for Criterion 1 may not also be used for Criterion 3.
The following page outlines the professional development criteria required for Pediatrics
certification. The criteria are based on the 5 AOTA Standards for Continuing Competence:
Knowledge, Critical Reasoning, Interpersonal Skills, Performance Skills, and Ethical Practice
(AOTA, 2015).
Reference
American Occupational Therapy Association. (2015). Standards for continuing competence.
American Journal of Occupational Therapy, 69(Suppl. 3), 6913410055.
http://dx.doi.org/10.5014/ajot.2015.696S16
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
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Reflective Portfolio--Professional Development Activities
Instructions: Please indicate which of the 5 criteria in addition to criterion #11 that you
are submitting as part of this application.
X
Required
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.
2. Knowledge: Evaluation - Demonstrates acquisition of current knowledge of
relevant evidence specific to evaluation in pediatrics.
3. Knowledge: Intervention - Demonstrates acquisition of current knowledge of
relevant evidence specific to intervention in pediatrics.
4. Knowledge: Systems - Demonstrates acquisition of current knowledge of
laws, regulations, payer sources, and service delivery systems relevant to
pediatrics.
5. Evaluation: Uses Relevant Evidence –Uses relevant pediatric 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.
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.
7. Intervention: Design & Implementation - Ensures the design and
implementation of pediatric interventions that are client-centered, contextually
relevant, and evidence-based to facilitate optimal occupational engagement.
8. Intervention: Wellness & Prevention - Provides or facilitates pediatric
interventions that incorporate wellness and prevention for clients (persons,
organizations, populations) to optimize present and future occupational
engagement.
9. Outcomes - Ensures that that are services delivered, either for caseload or
programs, are validated and that changes are made as appropriate to
maximize outcomes related to pediatrics.
10. Holistic Practice - Ensures that client’s needs, including physical, social, and
emotional well-being, are addressed holistically to maximize occupational
performance in pediatrics.
11. 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.
12. Establishes Networks & Resources - Establishes or contributes to the
advancement of pediatric networks and collaborates with team members,
referral sources, or stakeholders to support clients’ occupational engagement.
13. Service to BASC – Demonstrates leadership in service to support BASC
operations.
14. Ethical Practice - Identifies ethical implications associated with practice in
pediatrics and applies ethical reasoning for navigating through identified issues.
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
12
ETHICAL PRACTICE SCENARIO (Part 1 of 3)—Client Based
Criterion 14—Ethical Practice: Client-Based
Identifies ethical implications associated with practice in pediatrics and applies ethical
reasoning for navigating through identified issues.
Guidelines
 The applicant identifies ethical implications associated with the delivery of services and articulates a
process for navigating through the identified issues.
 The applicant shall review the AOTA Code of Ethics and align the dilemma with the ethical principle(s)
that is/are challenged.
Ethical Scenarios
Scenario #1
The parents of a 7 year old girl with severe cerebral palsy pursue outpatient occupational therapy
to teach their daughter how to feed herself. After reviewing records, the OT determines that the
client has had 2-3 hospitalizations due to pneumonia in the past year. After a cursory oral-motor
assessment, the OT suspects there are swallowing problems that she has not been trained to
evaluate or treat.
Scenario #2
A 15 year old client with non-verbal autism is dependent for most of his self-care activities. After
some online reading, his parents ask the OT to provide sensory integration therapy 2 times a
week to help facilitate greater social interaction between their son and his peers.
Scenario #3
An infant was born at 25 weeks gestation with multiple upper extremity joint contractures. At a
corrected gestational age of 32 weeks, the OT fit and issued splints that gently elongate and
stretch the hand and wrist contractures. The splint wearing schedule was established
collaboratively with nursing. The family wants the OT to be more aggressive with her
intervention, including stretching the contractures multiple times a da.
1. To which scenario are you responding? _________
2. From the AOTA Code of Ethics, which ethical principle(s) has/have been challenged in this
scenario? Select the top ethical principle(s) that apply, up to a maximum of 3.
☐ 1. Beneficence
☐ 4. Justice
☐ 2. Non-maleficence
☐ 5. Veracity
☐ 3. Autonomy
☐ 6. Fidelity
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
13
3. Describe how you would apply the ethical principles identified above to guide you toward a
resolution for the concern noted. (average word guideline—500)
v
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
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ETHICAL PRACTICE SCENARIO (Part 2 of 3)—Fiscal & Regulatory
Criterion 14—Ethical Practice: Fiscal & Regulatory
Identifies ethical implications associated with practice in pediatrics and applies ethical
reasoning for navigating through identified issues.
Guidelines
 The applicant identifies ethical implications associated with the delivery of services and articulates a
process for navigating through the identified issues.
 The applicant shall review the AOTA Code of Ethics and align the dilemma with the ethical principle(s)
that is/are challenged.
Ethical Scenarios
Scenario #4
A family’s medical insurance plan allows for 20 visits each year. Their 12 year old daughter, who
has severe intellectual disability, visual impairment, and spastic quadriplegia, has had 12 visits
so far with no progress and was discharged from OT at another facility. The family is seeking
services from another provider for 8 additional visits in order to maximize their insurance benefit.
Scenario #5
An outpatient clinic is downsizing due to budget constraints. Treatment sessions that used to be
60 minutes long have been reduced to 45 minutes. However, therapists are required to bill for 4
units of therapy per session (1 unit = 15 minutes). OTs are also required to schedule clients
back-to-back every 45 minutes.
Scenario #6
Third party reimbursement has been exhausted at the pediatric outpatient clinic. The OT asks the
parent to request that the medically-based services, previously provided at the clinic, be
continued by the school-based OT, even though they are not educationally relevant. The client is
currently attending regular classes and meeting grade-level learning expectations.
1. To which scenario are you responding? _________
2. From the AOTA Code of Ethics, which ethical principle(s) has/have been challenged in this
scenario? Select the top ethical principle(s) that apply, up to a maximum of 3.
☐ 1. Beneficence
☐ 4. Justice
☐ 2. Non-maleficence
☐ 5. Veracity
☐ 3. Autonomy
☐ 6. Fidelity
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
15
3. Describe how you would apply the ethical principles identified above to guide you toward a
resolution for the concern noted. (average word guideline—500)
v
© 2016 The American Occupational Therapy Association, Inc. All rights reserved.
16
ETHICAL PRACTICE SCENARIO (Part 3 of 3)—Systems/Organizational
Criterion 14—Ethical Practice: Systems/Organizational
Identifies ethical implications associated with practice in pediatrics and applies ethical
reasoning for navigating through identified issues.
Guidelines
 The applicant identifies ethical implications associated with the delivery of services and articulates a
process for navigating through the identified issues.
 The applicant shall review the AOTA Code of Ethics and align the dilemma with the ethical principle(s)
that is/are challenged.
Ethical Scenarios
Scenario #7
A student with JRA is supported in his school under a 504 plan. A recent flare up results in a
physician referral for bilateral resting splints for night use. His parents ask the school OT, who
has not previously seen the student, to provide the splints and to speak with the teachers about
additional accommodations their son needs during this flare up.
Scenario #8
A practitioner with 10 years’ experience as an OT decides to switch from adult rehab to pediatrics
in order to have more flexibility in her work schedule. She attends an IFSP meeting for a child
and comes prepared with pre-established goals recommending 2 hours of intervention a week.
Scenario #9
A 20 month old toddler with a history of prematurity, chronic lung disease, PVL, and
developmental delays is referred to a multi-disciplinary feeding team for evaluation and
treatment for her failure to progress to solid foods. During an evaluation, the OT and SLP on the
team identify significant oral motor dysfunction and swallow safety risks. During a summary
conference with the family, the psychologist identifies the primary issue being the child’s refusal
behaviors and strongly recommends intervention focused primarily on those behaviors.
1. To which scenario are you responding? _________
2. From the AOTA Code of Ethics, which ethical principle(s) has/have been challenged in this
scenario? Select the top ethical principle(s) that apply, up to a maximum of 3.
☐ 1. Beneficence
☐ 4. Justice
☐ 2. Non-maleficence
☐ 5. Veracity
☐ 3. Autonomy
☐ 6. Fidelity
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
17
3. Describe how you would apply the ethical principles identified above to guide you toward a
resolution for the concern noted. (average word guideline—500)
v
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
18
PEDIATRICS RENEWAL APPLICATION
Part C. Goal Status and Reflection
As part of initial certification, applicants are asked to establish a professional development
plan related to the certification criteria that they will work on during the 5 years prior to the
next renewal.
A reflection on goal status ensures that practitioners continue to develop and grow
professionally, working toward targeted goals and revising them as warranted.
Guidelines


Review the status of goals that were established in the initial certification application.
Note if any changes were made to the original goals.
What is the status of these goals? Do you feel the goal – as initially written or
modified – was achieved?
Parameters


All goals that were identified in the initial application are addressed, and all goals are
identified as having been met or, if there were changes, the rationale for change.
Narrative includes a reflection on the value of goals in helping applicant grow
professionally.
Applicant's Reflection on Goals
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
19
PEDIATRICS RENEWAL APPLICATION
Part D. Self-Assessment
Self-assessment is a formative and dynamic process through which occupational therapy
practitioners identify goals for professional development and monitor progress toward goals
(Moyers, 2010). Self-assessment answers the question, “What can I do to prepare or
increase my capacity for the competency demands of the future?” In the Board Certification
process applicants will use self-assessment to consider all that they have learned thus far in
their achievement of the certification criteria. This self-understanding combined with ideas
about the way practice is changing will help applicants determine what they should learn
next.
Reference
Moyers, P. A. (2010). Competence and professional development. In K. Sladyk, K. Jacobs, &
N. MacRae (Eds.), Occupational therapy essentials for clinical competence (pp. 475484). Thorofare, NJ: Slack.
Guidelines

Develop the self-assessment by answering the questions below in a single narrative
as they relate to the certification criteria collectively. Use examples to support the
answers.

The average answer is 1,350–3,000 words.
Self-Assessment Questions:
 Describe your current practice in relation to this certification and how you envision
your practice area changing in the future.
 Having gone through the certification process, what have you discovered that you
want to learn more about in relation to the competencies required for this certification
area?
Applicant's Self-Assessment
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
20
PEDIATRICS RENEWAL APPLICATION
Part E. Professional Development Plan
Professional development planning in the AOTA certification process requires that applicants
develop a plan for learning for the next 5 years related to the certification criteria.
Depending on personal style or the specific criterion selected, goals might emphasize
outcome, performance, or process; but it is possible for a goal to include a combination of
these elements:



Outcome – what are you trying to achieve?
Performance – what task will you complete?
Process – what specific actions will you take?
Guidelines
Each goal must include the following qualities:

It must be relevant to the identified criterion. For example, an applicant goal to
“learn a new assessment tool” would not be relevant to a criterion that deals with
"advancing access to OT services."

It must be measureable. There must be an objective way for the applicant to
demonstrate a change toward meeting the goal in the next 5 years.

It must controllable by the applicant. The applicant should be able to meet the goal
regardless of the external environment. For example, a goal to "Discharge all
patients safely to home" is not something than can be realistically controlled by the
applicant.
It should reflect advanced practice in Pediatrics and build on already established
skills versus representing what a good entry level practitioner would be expected to
do. If the goal represents a new direction for the applicant; while the actions
represented in the goal may be not be advanced in and of themselves, the thinking
of the applicant and application to practice should reflect advanced critical reasoning.

Parameters

Establish 3 professional development goals.

Do not develop more than 1 goal for a single criterion; 3 different criteria must be
represented.

Include strategies, success criteria, and target date for completion in goals, which
should also be relevant to your practice.

Write unique goals that do not simply reiterate the criterion.

Develop goals that represent your own professional development, not the
development of others (e.g., students, other staff).
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
21
Professional Development Goal 1
To which criterion does this goal apply (check 1)?
☐
☐
☐
☐
☐
☐
☐
Knowledge: Lifespan & Conditions
Knowledge: Evaluation
Knowledge: Intervention
Knowledge: Systems
Evaluation: Uses Relevant Evidence
Evaluation: Prioritizes Needs
Intervention: Design & Implementation
☐
☐
☐
☐
☐
☐
Intervention: Wellness & Prevention
Outcomes
Holistic Practice
Ethical Practice
Advocating for Change
Establishes Networks & Resources
☐
☐
☐
☐
☐
☐
Intervention: Wellness & Prevention
Outcomes
Holistic Practice
Ethical Practice
Advocating for Change
Establishes Networks & Resources
☐
☐
☐
☐
☐
☐
Intervention: Wellness & Prevention
Outcomes
Holistic Practice
Ethical Practice
Advocating for Change
Establishes Networks & Resources
Applicant’s Goal 1:
Professional Development Goal 2
To which criterion does this goal apply (check 1)?
☐
☐
☐
☐
☐
☐
☐
Knowledge: Lifespan & Conditions
Knowledge: Evaluation
Knowledge: Intervention
Knowledge: Systems
Evaluation: Uses Relevant Evidence
Evaluation: Prioritizes Needs
Intervention: Design & Implementation
Applicant’s Goal 2:
Professional Development Goal 3
To which criterion does this goal apply (check 1)?
☐
☐
☐
☐
☐
☐
☐
Knowledge: Lifespan & Conditions
Knowledge: Evaluation
Knowledge: Intervention
Knowledge: Systems
Evaluation: Uses Relevant Evidence
Evaluation: Prioritizes Needs
Intervention: Design & Implementation
Applicant’s Goal 3:
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
22
PEDIATRICS RENEWAL APPLICATION
Completion Guidelines and Attestation
Item(s) to Submit
1. The following should be sent to [email protected] by the application deadline. A single
combined document, preferably PDF, is encouraged.
A. Certification Application (this document)
B. Employment/Volunteer Verification Form
C. Professional development activity forms
D. Any additional evidence as required by a particular activity (e.g., CE certificates)
2. Renewal application fee of $475 (submitted separately from application):

Credit card: Call (800) SAY-AOTA (800-729-2682) extension 1708

Check: Mail check on or before the application deadline to
Monday- Friday between 9:00-5:00 Eastern to pay by phone. If no answer, please leave a
message and your call will be returned by the end of the week. You will not be considered
late. Please do not leave a CC number in the message.
Attn: Certification - AOTA
4720 Montgomery Lane
Bethesda, MD 20814-3449
Applicant Attestation
I hereby attest that the information provided in this application is my own and that I have
complied with all Principles and Standards of Conduct of the Occupational Therapy Code of
Ethics , including Beneficence; Non-maleficence; Autonomy, Confidentiality; Justice;
Veracity; and Fidelity. If granted certification, I will not use my credential to represent
myself to others beyond the level for which I am qualified.
Signature (electronic signature acceptable)
Date
© 2017 The American Occupational Therapy Association, Inc. All rights reserved.
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