San Juan College
Occupational Therapy Assistant Program
Application 2016
Welcome
The San Juan College Occupational Therapy Assistant Program is a selective program and admission
is limited. Students seeking to enter must complete the following application and all required steps
prior to May 25, 2016 at 5:00pm. We look forward to receiving your application!
If you have any questions regarding the application process, please do not hesitate to contact us:
Occupational Therapy Assistant Program
Phone: (505) 566-3849 / Fax (505) 566-3647
[email protected]
2016 Application-A
Instructions for Applying to the OTA Program
Apply to San Juan College and submit all official transcripts:
 Contact the San Juan College Admissions Office for a San Juan College Application for Admission ($10
for paper application) or apply free online at www.sanjuancollege.edu. Declare your major as
AS.LBAS.OTAP on the San Juan College Application.
 Send ONE official transcript from EACH college, university, and high school that you attended to the
San Juan College Admissions Office.
San Juan College
Admissions Office
4601 College Blvd.
Farmington, NM 87402
(505) 566-3300
OTA Program Prerequisites:
 Contact the San Juan College OTA Program at (505) 566-3849 or [email protected] to arrange an
appointment to review unofficial transcripts from EACH college and university that you have attended
for prerequisite information. Other detailed program information including that individuals who have
been convicted of a felony or some misdemeanors may not be eligible for certification or licensure will also
be reviewed.
Send the following OTA Program Application materials to the OTA Program IN ONE SEALED ENVELOPE:
☐ Completed OTA Program Application 
☐ Two (2) Completed Letter of Recommendations in sealed envelopes with signature over seal
☐ Completed “Verification of Observation Hours” Form and “Reflection of Observation Hours” Form
☐ Copy of Page 1 of results of your ATI TEAS V for AH Admissions Exam, taken between May 2014 &
May 2016
☐ Sign Acknowledgement Page, including reading the Essential Functions of an OTA
All the materials must be received at the OTA Program before 5 pm on Wednesday, May 25, 2016:
San Juan College
OTA Program
Health Science Center #3010
4601 College Blvd.
Farmington, NM 87402
[email protected]
Confirm that the OTA Program Application packet has been received by May 25, 2016.
 Email the OTA Program at [email protected] to confirm that the OTA Program has received the
application packet on time.
Deadlines:
ATI TEAS V for AH Exam
Deadline
March 15-April 23, 2016
Application Deadline
Decision Date
Program Start Date
May 25, 2016
June 27, 2016
August 22, 2016
2016 Application-B
2016 Selection Criteria
SJC OTA Program will accept a maximum of 20 students in 2016. Applicants will be ranked based on the
following criteria:
Criteria
Comments
Points
Prerequisite GPA
70
(Minimum of 2.75 out of 4.0)
ATI TEAS V for AH Exam
20
(Health Occupations Basic Entrance Test)
Letters of Recommendation (2 @ 5 each)
10
Bonus:
5
New Mexico Residency
Per SJC Admissions Policy
Overall GPA for Tie Breakers
If there is a tie to the hundredth percent then the
Overall GPA for all course work will break the
tie.
TOTAL Points Possible 105
FINANCIAL AID:
Financial Aid is available for students who qualify:
San Juan College
Financial Aid
4601 College Blvd.
Farmington, NM 87402
505-566-3323
LEGAL LIMITATIONS:
Individuals who have been convicted of a felony or some misdemeanors may not be eligible for
certification or licensure. If convicted of a felony or some misdemeanors, you must contact the
Occupational Therapy Licensing Board in the state where you plan to seek licensure to verify your
eligibility for licensure. The New Mexico Administrative Code, Section 16.15.2.9 states, “Questions
of felony convictions or misdemeanors involving moral turpitude have to be satisfactorily
resolved. The board may require proof that the person has been sufficiently rehabilitated to
warrant the public trust. Proof of sufficient rehabilitation may include, but not be limited to;
certified proof of completion of probation or parole supervision, payment of fees, community
service or any other court ordered sanction”.
All students accepted into the SJC Occupational Therapy Assistant Program will be required to
complete a criminal background check at their own expense and provide a copy to the OTA
Program. Some fieldwork sites may require additional background checks at the student’s expense.
Individuals who have been convicted of a felony or some misdemeanors may have limited
employment opportunities in the field of occupational therapy.
2016 Application-C
ESSENTIAL PHYSICAL AND MENTAL ABILITIES REQUIRED OF THE OCCUPATIONAL
THERAPY ASSISTANT:
The following are technical standards and essential job functions for every Occupational Therapy Assistant, as compiled from
observations of a wide variety of job experiences for the performance of common safe therapeutic functions. Students accepted into the
Occupational Therapy Assistant Program at San Juan College should exhibit or demonstrate the following essential skills for
completion of the program and success in the profession of Occupational Therapy. These technical standards must be met and
maintained throughout the length of the Program.
Functional use of vision, hearing, and physical sensations required to:

visually observe carefully and with enough acuity to participate actively in laboratory exercises and clinical experiences,
including but limited to movement, posture, body mechanics

read small printed materials, such as a medical record, calibrations or symbols on equipment, and computer screens

hear sufficiently to perceive normal tone of voice to follow directions, participate in conversations, answer phones and
intercoms

hear sounds produced by the body via the use of a stethoscope

assess and treat all clients assigned to student, including palpation of the client
Sufficient motor ability, agility, and strength required:

to frequently execute safe and effective transfers of adults and children, in excess of 100 pounds

to treat clients in daily meaningful activities, cardiopulmonary resuscitation, and emergencies, including but not limited to:
balancing, stooping, kneeling, crouching, crawling, reaching or climbing

to grasp and manipulate various sizes of equipment needed for therapeutic interventions, splinting, or data entry

to administer a variety of massages and other manual therapies
Ability to communicate effectively in English:

with enough volume to express one’s thoughts verbally and distinctly, including medical terminology

to perceive non-verbal communication, such as, changes in mood, activity, facial expression and postures

using legible hand-writing and electronic formats

present essential information in summary and in precise and specified formats
Intellectual ability to make sound and safe decisions relevant to the treatment and care of patient/clients through:

reading, comprehension, and retention of textbooks, medical records, and professional literature

reasoning and problem solving while participating with clients and selecting effective therapeutic activities

data collection and interpretation of material from medical records
Possess professional behaviors of:

emotional health and stability to complete complex patient care responsibilities within an allotted time

tolerate taxing academic and clinic workloads

flexibility to function and remain calm under stressful conditions, including emergency situations in the clinic

perform independently and safely with minimal supervision

compassion, integrity, and strong work ethic

learn to function in the face of uncertainties inherent in clinical settings with patients

track and complete multiple tasks meeting deadlines

effectively interact with diverse populations and personalities individually and in group settings

work in close physical contact with others
ETHICS
Faculty and students abide by the Code of Ethics for Occupational Therapy practitioners in the state of New Mexico and the AOTA
Code of Ethics.

Information concerning Occupational Therapy practitioners and Ethics for New Mexico can be found in the New Mexico
Administrative Code at Title 16, Chapter 15, Part 5 or http://www.nmcpr.state.nm.us/nmac/cgibin/hse/homepagesearchengine.exe?url=http://www.nmcpr.state.nm.us/nmac/parts/title16/16.015.0005.htm;geturl;terms=occu
pational+therapy||code+of+ethics
AOTA Code of Ethics is found at http://www.aota.org/-/media/corporate/files/practice/ethics/code-of-ethics.pdf
2016 Application-D
Non-Discrimination Policy
San Juan College will comply with existing federal and state laws and regulations, including the Title VII Civil Rights
Act of 1964 and 1990, Executive Order 11246 Section 504 of the 1973 Rehabilitation Act, the Age Discrimination Act of
1967, the Americans with Disability Act of 1990, as amended, and the Vietnam Era Veteran’s Readjustment Act of
1974. It is the policy of the College to provide for equal opportunity in recruitment, employment, compensation,
benefits, transfers, layoffs, returns, institutionally sponsored education, training, tuition assistance, social and
recreational programs, staff development opportunities and advancement, and all other personnel practices without
regard to race, color, religion, national origin, ancestry, sex, disability, age, or veteran’s status. Questions should be
directed to the EEO officer at 505-566-3253.
Program Cost
Based on a full-time student accepted in the OTA Program at San Juan College
Costs are subject to change at any time.
Fall-Semester 1
Spring-Semester 2
Resident
Non-Resident
Resident
Non-Resident
Tuition/Fees*
$996.00
$2,316.00
Tuition/Fees*
$996.00
$2,316.00
Books1
$648.60
$ 648.60
Books1
$364.59
$ 364.59
2
2
Misc.
$460.00
$ 460.00
Misc.
$ 75.0
$
75.0
Professional3
$ 75.00
$ 75.00
Professional3
0
0
________
________
________
________
Total**
$2,179.60
$3,499.60
Total**
$1,435.59
$2,755.59
Summer-Semester 3
Fall Semester 4
Resident
Non-Resident
Resident
Non-Resident
Tuition/Fees*
$675.50
$1,395.50
Tuition/Fees*
$1,176.00
$2,496.00
Books1
$195.20
$ 195.20
Books1
$ 185.70
$ 185.70
2
2
Misc.
0
0
Misc.
$ 120.00
$ 20.00
Professional3
$ 80.00
$ 80.00
Professional3
$ 100.00
$ 100.00
________
________
________
________
Total**
$ 950.70
$1,670.70
Total**
$1,581.70
$2,901.70
Spring Semester 5
Estimated Totals for Entire Program
Resident
Non-Resident
Resident
Non-Resident
Tuition/Fees*
$1,056.00
$2,386.00
1st Semester
$2179.60
$3499.60
1
nd
Books
$0.00
$0.00
2 Semester
$1435.59
$2755.59
Misc.2
$ 75.00
$ 75.00
3rd Semester
$ 950.70
$1670.70
Professional3
$ 820.00
$ 820.00
4th Semester
$1581.70
$2901.70
th
________
________
5 Semester
$1951.00
$3281.00
Total**
$1,951.00
$3,281.00
All Semesters
$8,098.59
$14,018.59
*All Tuition and Fees are subject to change. Please refer to the semester schedule in reference for current rates. Fees
may include but are not limited to: Technology Fee, Student Activities Fee, and Lab Fee.
Books1 These expenses are estimated and may be paid to outside vendors. Book costs are estimated based on new textbook costs at
the time of printing.
Misc.2 This includes mandatory expenses of Criminal Background Check, immunizations (varies, may be over $1000.00), CPR
Certification, physical examination, 10-Panel Drug Screen, graduate cap and gown. Other expenses may include: uniforms,
shoes, equipment, etc. which are paid to outside vendors of the student’s choice.
Professional3 These expenses are related to professional organization membership, certification practice exams, certification exams,
licensure, etc.
**Total is an estimate of all costs related to the program whether required paid to the college or to an outside vendor at the student’s
discretion. Additionally, students are responsible for travel and/or housing costs for all fieldwork rotations; one of the Level II
Fieldwork (2-month) rotations will be outside of the Four Corners Region.
2016 Application-E
INSTRUCTIONS FOR LETTERS OF RECOMMENDATION:
Choose ONLY TWO people who will be submitting letters of recommendation on your behalf using the
recommendation form provided in the application packet. The recommenders are being asked to evaluate the
applicant’s personal and professional behaviors. One recommendation must be from someone who has
supervised you in a work or volunteer experience. The other recommendation may be from an
instructor/professor, counselor/advisor, health care professional, previous/current employer, or community
leader/representative. Recommendations from family or personal friends are UNACCEPTABLE.
Print and sign your name in the appropriate spaces on the Letter of Recommendation form AND provide
your recommender with a self-addressed stamped envelope with your address to return to you for you to
include in your application packet.
INSTRUCTIONS FOR OBSERVATION OF OCCUPATIONAL THERAPY:
All applicants must complete 6 total hours of observation in 2 different occupational therapy settings (skilled
nursing facility, hospital, rehabilitation centers, mental health facilities, home-health, out-patient, school
district, etc.) under the supervision of an occupational therapist or an occupational therapy assistant. The
purpose of the experience is to give the applicant an opportunity to observe treatment, gain insight into the
profession of occupational therapy and to ensure that this career meets your expectations and needs. It is the
responsibility of the applicant to make arrangements with an OT/OTA for this experience. The applicant is also
responsible for having the supervising therapist complete the “Verification of Observation” form. All forms
must be included with the application packet by the deadline.
Guidelines for observation experience:
1. If you are employed where you have direct patient contact AND interaction with an Occupational
Therapy Practitioner, you may use your worksite for ONLY ONE of your observation sessions.
2. Observations with Occupational Therapy Practitioners may have occurred as early as January 2014.
3. Contact facilities in your area. Explain that you are applying to an OTA program and that you would
like to observe either an OT or OTA at their site. It is up to the applicant and therapist to agree on the
schedule. Remember this is a voluntary service provided by the clinician and facility.
4. Dress appropriately. Follow the professional dress code of the facility, usually slacks, polo shirt, and
tennis shoes are acceptable. No shorts, jeans, t-shirts, hats, sandals, heavy make-up, excessive
perfume/cologne, or body piercings. Any visible markings (e.g. tattoos) should be covered.
5. Be punctual & prepared. Make sure that you know who, when, and where you will be meeting. Please
call 24 hours in advance to cancel or reschedule your appointment. Complete the sections on the
Verification of Observation form relating to the applicant. Take the form with you for signatures.
6. Maintain confidentiality. The facility may inform you about HIPAA (Health Insurance Portability and
Accountability Act) and ask you to sign a form that you will comply with this. The OT or OTA may
choose to share relevant information with you before or after the treatment session. Never mention a
patient’s name, medical diagnosis, or treatment plan outside of the facility.
2016 Application-F
7. During the observation visit. Remain in the area(s) assigned to you by the staff member. Follow all
instructions the practitioner gives you, especially concerning how much you are to interact with the
clients. Do not ask personal questions about the patient during the occupational therapy treatment
session.
8. Completion of observation time. Provide the Occupational Therapy Practitioner with the Verification
of Observation form to fill in the time started and ended, total hours observed and signature. Take the
Verification form with you for other observation sites and to include with your application.
9. Thank the occupational therapy practitioner. Thank the clinician for allowing you to observe at their
facility. Remember that this is an observation only and that you are not allowed to assist with any
treatment due to liability issues. Professional protocol encourages you to send a formal thank you note
to the OT practitioner after you finish the hours of observation.
10. Complete Application Section H-Reflection of Observation Hours - after leaving the facility.
INSTRUCTIONS FOR ATI TEAS V for AH EXAMINATION:
Below are specific directions from the Testing Center for both remote and local directions to take the
ATI TEAS V for AH exam.
Please include ONLY the first page of your ATI TEAS V for AH exam results in the SJC Occupational
Therapy Assistant Program application packet.
Details:
 Occupational Therapy Assistant Test Dates:
o March 15, 2016-April 23, 2016
o September 20, 2016-October 22, 2016
 The testing appointment will be 3.5 hours.
 Study guide available at: http://www.atitesting.com/ati_store/product.aspx?zpid=1175
 The testing fee is non-refundable.
2016 Application-G
ATI TEAS V for AH
Step-by-Step Guide
IMPORTANT – READ CAREFULLY!!
Step 1
Step 2
Step 3
Step 4
Step 5
Pay the $80.00 fee at the SJC Business Office in the Administration Building
(Clock Tower Building) or by calling the Business Office at 505-566-3396. Keep
the receipt number. This fee is non-refundable.
Create an ATI account at www.atitesting.com
Bring your username and password to launch the exam on test day.
Schedule your appointment online at www.sanjuancollege.edu/test Please
schedule your exam at least 72 hours in advance. The receipt number is required
to make an appointment.
Check in at the Testing Center, Room 7120D, Information Technology Center 15
minutes before your scheduled time. Bring government issued photo ID.
Read the Rules for Use of the Testing Center carefully so you will know what to
expect on the day of your appointment.
Details:
 Test appointments are scheduled on Tuesdays – Saturday 8:30 AM or
1:00 PM. (Saturday appointments are NOT available during summer schedule.)
 $25.00 No Show Fee. Please call at least 24 hours in advance to reschedule your test
appointment to avoid the No Show Fee.
 ATI TEAS V for AH - Students may take the exam once per semester, such as once in
spring, once in the summer, with 45 days between test dates.
 The test appointment will be 3.5 hours in duration.
Program
Test
Dates 2016
Occupational Therapy Assistant Program
ATI TEAS V for AH
3/15-4/23/2016
9/20-10/22/2016
San Juan College Testing Center
Room 7120, Information Technology Center
(505) 566-3139 www.sanjuancollege.edu/test
Study guide available at: http://www.atitesting.com/ati_store/product.aspx?zpid=1175
2016 Application-H
Rules for ATI Testing
 Bring proper identification (such as a driver’s license or a passport) that includes:
o A current photograph
o Your signature
o A permanent address
 Bring your ATI user name and password to launch exam.
 Special accommodations due to a disability or medical condition must be arranged in
advance with the Director of Testing and the Students with Disabilities Office.
Appropriate documentation will be required.
 If you are ill or have a fever, please call to reschedule. We do not want to pass along flu
or other contagious illnesses. There is a $25.00 no show fee.
 If examinees wear excessive perfume, cologne, or other strong smelling lotions/sprays
they could be asked to reschedule the exam.
 Only testing candidates are allowed in our testing rooms or waiting areas.
 Everything you need for the actual test will be provided. You will NOT be allowed to
take any personal items into the testing room.
 The ATI exam fee is non-refundable.
Prohibited Items may be stored in one of our lockers.
Testing Candidates may NOT bring the following into the testing room:
o purses
o books or backpacks
o cell phones, mp3 players or any other electronic devices
o car key fob
o cameras
o food, candy, gum, cough drops or beverages
o hats, hoodies
o watches, digital or analog
San Juan College Testing Center
Room 7120, Information Technology Center
(505) 566-3139 www.sanjuancollege.edu/test
2016 Application-I
Guidelines for ATI Remote Testing
ATI TEAS V for AH
Step 1
Step 2
Step 3
Step 4
Locate an official testing center at your local community
college or university to schedule your remote testing
appointment (ask if they can proctor an internet based exam).
Another option is to search the list of testing centers by
location at the Consortium of College Testing Centers
website.
Contact the San Juan College Business Office to pay the
$80.00 fee for remote testing at 505-566-3396. This fee is
non-refundable.
Complete the Request for Remote Proctored Exam form.
Include all requested information. Send it to the SJC Testing
Center via email at [email protected] or via
fax at (505) 566-3455. Please schedule the start of your exam
during our business hours (Mountain Time) so that we can
assist if there are any technical problems. We will work with
your testing center to administer this exam.
Please note: The Testing Center must receive the completed
Request for Remote Testing five (5) business days prior to
your scheduled exam to allow for contact with your testing
center.
Create an ATI account:
www.atitesting@com
Bring your username and password to launch the exam.
Details:
 The testing appointment will be 3.5 hours.
 TEAS V for AH – Students may take the exam once per semester, such as once
in spring, once in the summer, with 45 days between test dates.
Program
Test
Dates 2016
Occupational Therapy Assistant Program
ATI TEAS V for AH
3/15-4/23/2016
9/20-10/22/2016
San Juan College Testing Center
Room 7120 Information Technology
Center (505) 566-3139
Study guide available at: http://www.atitesting.com/ati_store/product.aspx?zpid=1175
2016 Application-J
Request for
Remote
ATI TEAS V for AH Exam
Schedule your exam during our business hours:
Tuesday – Saturday 8:30A.M. – 4:30P.M.
Fee
$80.00 for remote testing
Date Paid
Receipt Number
Personal information: All fields are required.
Last
First
Email Address*
Birth Date
Daytime Phone
(
)
Evening Phone
(
)
Middle
SJC ID # or last 4 digits of SS #
Street
City
State
Remote Testing Center Information
Testing Center Name
Testing Center phone number
Contact Person
Title of Contact
Test Date and time (Mountain Time)
Date
Time
Email
Zip
For SJC Testing Center Staff
Email sent:
Date/Person Contacted:
Email or fax this form to the San Juan College Testing Center
[email protected] fax: (505)566-3455
2016 Application-K
Section A-Personal Information
LAST
M.I.
FIRST
MAIDEN
1) Name of Applicant
Preferred Name
2) San Juan College ID #
Last FOUR digits
of your SSN#
STREET NAME & NUMBER
APT. #
CITY
STATE
ZIP CODE
STREET NAME & NUMBER
APT. #
CITY
STATE
ZIP CODE
3) Physical Address
4) Mailing Address
5) E-Mail Addresses
A.
Personal/Work (Circle One)
B.
Personal/Work (Circle One)
6) Home Phone Number
(
)
7) Work Phone Number
(
)
8) Cell Phone Number
(
)
9) Preferred Method of
Contact
10) Emergency Contact
Information #1
11) Emergency Contact
Information #2
NAME
RELATIONSHIP
STATE
DAYTIME PHONE
EVENING PHONE
CELL PHONE
NAME
RELATIONSHIP
STATE
DAYTIME PHONE
EVENING PHONE
CELL PHONE
Are you a New Mexico Resident?
☐Yes ☐No
Are you a resident of any one of the following Colorado counties?
☐Yes ☐No
(Montezuma, Archuleta, Dolores or San Juan)
Students meeting the residency and/or special residency status as defined in the San Juan College
Academic Catalog will be given a 5% Residency Preference on their application.
2016 Application-1
Section A-Personal Information, continued
Have you ever been convicted of a felony:
Have you ever been convicted of a misdemeanor:
If yes, have you contacted the Occupational Therapy Licensing Board in your
state:
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
TELL US WHY YOU WANT TO GET INTO SJC OTA PROGRAM:
In the space below, reflect on your Occupational Therapy Observation time. Please explain how the experience deepened
your understanding of Occupational Therapy and solidified your reasoning for seeking Occupational Therapy Assistant
as a career choice.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
COMPUTER SKILLS REQUIRED FOR THE OTA PROGRAM:
Students in the OTA Program must be able to use a computer. Computer skills required include:
email, accessing and using the SJC Canvas course delivery system, creating documents and
presentations, uploading and downloading information to and from the internet. All students must
have access to a computer on a regular basis. Students are NOT required to have a personally owned
computer or home-based high speed internet access as these materials and services are made readily
available at all SJC campuses.
Section B-ATI TEAS V for AH Exam Results
Please document the date of your ATI TEAS V for AH Exam in the table below and include a copy of the FIRST PAGE of
the ATI TEAS V for AH results with your application packet.
Date of Exam:
Copy of First Page of Results Attached to Application:
☐Yes ☐No
2016 Application-2
Section C – Educational Institutions
Please list all Educational Institutions, High School and above, and Health Related Programs you have attended in the order you
attended them.
1.
Name of High School:
City:
State:
Graduation Date:
GED Score:
2.
Name of Institution:
City:
State:
Dates Attended:
Health Related Program:
☐Yes ☐No
Degree(s) and Major
and/or Certificate(s)
Accomplished:
3.
Name of Institution:
City:
State:
Dates Attended:
Health Related Program:
☐Yes ☐No
Degree(s) and Major
and/or Certificate(s)
Accomplished:
4.
Name of Institution:
City:
State:
Dates Attended:
Health Related Program:
☐Yes ☐No
Degree(s) and Major
and/or Certificate(s)
Accomplished:
2016 Application-3
Section D – Educational Courses
Please fill out the Prerequisite Courses you have completed, in the chart below.
Send Official transcripts directly to San Juan College Office of Admissions.
PREREQUISITE
COURSES
COURSE ID
(e.g. BIOL
121)
COURSE TITLE
FINAL
GRADE
YEAR &
SEMESTER
COMPLETED
INSTITUTION
WHERE COURSE WAS
TAKEN
Course
Equivalent
(for office use
only)
Freshman
Composition
ENGL 111
OR
Technical
Composition
ENGL 118
Math for Health
Careers OR
MATH 114, 130,
Introduction to
Psychology
PSYC 120
Public Speaking
SPCH 110
OR
Interpersonal
Comm.
SPCH 111
Medical
Terminology
HITP 110
Human Body
Structures &
Functions
BIOL 112*
Musculoskeletal
Focus for PTA and
OTA
PTAP 116 *
*Anatomy and Physiology I and II (BIOL 252 and BIOL 253) may be accepted in place of BIOL 112 only with the OTA program
director’s permission. BIOL 112 is a prerequisite to PTAP 116. BIOL 112 is non-transferable.
BIOL course must be no older than 5 years.
2016 Application-4
In Progress Courses:
If you currently have courses in progress at the time of application, please have your Professor
complete the attached form and mail it directly to the SJC Occupational Therapy Assistant
Program. Please use one form for each instructor. You may copy this form as necessary.
In-Progress Grade Report Form
Dear Professor,
Your student is applying for the SJC Occupational Therapy Assistant Program and has asked you to
forward their in-progress grade in your course as part of the Application Process. Please fill out the
form below and mail this letter directly to the SJC Occupational Therapy Assistant Program at the
address below.
Thank you very much for your assistance.
San Juan College
Occupational Therapy Assistant Program
4601 College Blvd.
Health Science Center #3010
Farmington, NM 87402-4699
_____________________________________________________________________
(Student name)
is currently enrolled in
___________________________________________________________________________________________
(Class Name and Section)
at
____________________________________________________________________
(Name of Institution)
His/Her current grade is______________________________
Instructor’s Name______________________________________________________________________
Instructor’s Signature__________________________________________________________________
Date__________________________
2016 Application-5
Section E – Previous Work/Volunteer Experience
(Copy and include attachments as necessary)
Job Title
Organization’s Name
Name of Organization
Dates
Hrs/week
worked
Month/Year to Month/Year
Indicate Type of Experience:
Work / Volunteer
List Work or Volunteer Responsibilities/Skills
Job Title
Organization’s Name
Name of Organization
Dates
Hrs/week
worked
Month/Year to Month/Year
Indicate Type of Experience:
Work / Volunteer
List Work or Volunteer Responsibilities/Skills
Job Title
Organization’s Name
Name of Organization
Dates
Hrs/week
worked
Month/Year to Month/Year
Indicate Type of Experience:
Work / Volunteer
List Work or Volunteer Responsibilities/Skills
Job Title
Organization’s Name
Name of Organization
Dates
Hrs/week
worked
Month/Year to Month/Year
Indicate Type of Experience:
Work / Volunteer
List Work or Volunteer Responsibilities/Skills
2016 Application-6
Section F – Letter of Recommendation #1
Printed Applicant Name:
Note to the Applicant:
Complete the top section before forwarding it to your recommender. Provide your recommender with a self-addressed
stamped envelope so the individual can return the form directly to you.
I hereby waive my right to access this letter of recommendation to encourage the reference to provide a candid
assessment. As well, this letter will remain confidential. I understand that a letter of recommendation from a personal
friend or family member is UNACCEPTABLE.
_________________________________________________
Signature of Applicant
_________________________________________
Date
Recommender Name:
Signature & Date:
Note to the Recommender:
Thank you for assisting the above named person in applying to the San Juan College Occupational Therapy Assistant
Program. Applicants of the San Juan College Occupational Therapy Assistant Program are required to select TWO
references to complete this form. The form is intended to provide insight into the personal and professional behaviors of
the applicant. The SJC OTA admission committee requests that you complete this form with all honesty to ensure that the
most appropriate students are selected for our program. Upon completion of the evaluation, please place the form in the
attached self-addressed stamped envelope with your signature across the seal and returned to the student.
1. I have known the applicant for: ______ months or ______ years
2. Relationship to applicant: ____________________________________________
3. I feel that I know the applicant: ☐very well
☐well
☐not very well
4. Please rate the applicant by checking the number that best reflects your judgment about the applicant:
5
Very Well/Often
1
Poorly/Seldom
Attributes
5
4
3
2
1
Writes and speaks with organization and clarity
Relates effectively to persons in authority
Responds maturely verbally and non-verbally to others
Constructively works with others
Uses time responsibly and is prompt
Follows directions well and asks for clarification
Demonstrates self-confidence
Utilizes effective processes to solve problems
Accepts responsibility for his/her behavior and is ethical
Is flexible/adaptable
Works independently
Demonstrates initiative
Grasps new concepts quickly
Dresses appropriate to situation
Demonstrates safety awareness
The SJC OTA Selection Committee thanks you for your willingness to assist in this selection process.
N/A
2016 Application-7
Section F – Letter of Recommendation #2
Printed Applicant Name:
Note to the Applicant:
Complete the top section before forwarding it to your recommender. Provide your recommender with a self-addressed
stamped envelope so the individual can return the form directly to you.
I hereby waive my right to access this letter of recommendation to encourage the reference to provide a candid
assessment. As well, this letter will remain confidential. I understand that a letter of recommendation from a personal
friend or family member is UNACCEPTABLE.
_________________________________________________
Signature of Applicant
_________________________________________
Date
Recommender Name:
Signature & Date:
Note to the Recommender:
Thank you for assisting the above named person in applying to the San Juan College Occupational Therapy Assistant
Program. Applicants of the San Juan College Occupational Therapy Assistant Program are required to select TWO
references to complete this form. The form is intended to provide insight into the personal and professional behaviors of
the applicant. The SJC OTA admission committee requests that you complete this form with all honesty to ensure that the
most appropriate students are selected for our program. Upon completion of the evaluation, please place the form in the
attached self-addressed stamped envelope with your signature across the seal and returned to the student.
1. I have known the applicant for: ______ months or ______ years
2. Relationship to applicant: ____________________________________________
3. I feel that I know the applicant: ☐very well
☐well
☐not very well
4. Please rate the applicant by checking the number that best reflects your judgment about the applicant:
5
Very Well/Often
1
Poorly/Seldom
Attributes
5
4
3
2
1
Writes and speaks with organization and clarity
Relates effectively to persons in authority
Responds maturely verbally and non-verbally to others
Constructively works with others
Uses time responsibly and is prompt
Follows directions well and asks for clarification
Demonstrates self-confidence
Utilizes effective processes to solve problems
Accepts responsibility for his/her behavior and is ethical
Is flexible/adaptable
Works independently
Demonstrates initiative
Grasps new concepts quickly
Dresses appropriate to situation
Demonstrates safety awareness
The SJC OTA Selection Committee thanks you for your willingness to assist in this selection process.
N/A
2016 Application-8
Section G – Verification of Observation Hours
SAN JUAN COLLEGE
Occupational Therapy Assistant Program
4601 College Blvd.
Health Science Center #3010
Farmington, NM 87402
www.sanjuancollege.edu/ota
Phone: 505.566.3849
Fax: 505.566.3767
OCCUPATIONAL THERAPY ASSISTANT OBSERVATION FORM
Applicant’s Name: _________________________________
Phone Number:
_________________________________
To the Clinician: This person is applying to the San Juan College Occupational Therapy Assistant Program. The applicant must complete 6 hours of observation in
occupational therapy settings with 2 different populations such as a hospital & skilled nursing facility or out-patient facility & a school district. If you have questions,
please email us at [email protected]. The clinical observation hours are designed to give the applicant a better understanding of the role of OTs and OTAs in patient
care. Thank you for educating potential students about the profession.
Facility Information
Type
Skilled Nursing
Out-Patient
Name
San Juan Care
San Juan Regional Medical Center
Date
1.12.14
1.19.14
Observation Hours
Time
Time
In
Out
Examples
9:00 am
9:00 am
1:00 pm
12:30 pm
Total
Hours
4.0
3.5
OT/OTA Signature
Paula Peabody, OT
Dora Doer, OTA
2016 Application-9
Section H – Reflection of Observation Hours (To be completed only after facility visit)
OBSERVATION LOCATION #1
Name and Type of Facility visited
Location of OT treatment (gym, bedside, clinic)
Describe the client’s treatment (what you saw,
may include activities or equipment)
Describe the interaction between the client and
OT/OTA
What did you learn about OT during this time?
OBSERVATION LOCATION #2
Name and Type of Facility visited
Location of OT treatment (gym, bedside, clinic)
Describe the client’s treatment (what you saw,
may include activities or equipment)
Describe the interaction between the client and
OT/OTA
What did you learn about OT during this time?
2016 Application-10
MAKE AND KEEP A COPY OF THIS APPLICATION FORM FOR YOUR RECORDS.
Section I – Acknowledgement
Read and check each line, then at the bottom, date, print and sign your name
 I have read and understand what is required for the SJC Occupational Therapy Assistant Program
application process.
 I understand that I will be required to complete one of the Fieldwork Level II (2-month) rotations
outside of the Four Corners Region, which the OTA Program is responsible for coordinating. I
understand that travel and housing costs for all fieldwork rotations are my responsibility.
 I know to contact San Juan College Occupational Therapy Assistant Program, if I have any
questions about applying.
 I understand the deadline for all application materials is Wednesday, May 25, 2016 at 5:00 p.m.
 I understand that if required information is not included with my application for the SJC
Occupational Therapy Assistant Program that my application will not be considered.
 I understand that I am responsible to notify the program if any of the information contained herein
is changed or needs updating before notification of the selectees.
 I understand that if accepted to the program, I am required to complete a Criminal Background
Check, Immunizations, physical examination and/or other clinic related obligations at my own
expense.
 I understand that taking prerequisite courses toward the OTA program does not guarantee
acceptance into technical program courses or into the program.
 I must complete all of the prerequisite courses with a minimum “C” grade and have a minimum
prerequisite GPA of 2.75 for my application to be considered by the OTA Program. I will also be
required to maintain a “C” average of 75 points while in the OTA Program.
 I understand that admission into the SJC Occupational Therapy Assistant Program is competitive
and that applicants are assessed and ranked, with a maximum of 20 students being accepted for
Fall 2016.
 I have read and understand the Essential Physical and Mental Abilities required of the SJC OTA
program.
 I acknowledge that I am responsible for having the computer skills required for the SJC OTA
program. I acknowledge that I have regular access to a personal or public computer with high
speed internet.
I certify this application to be correct and complete. Any false statements knowingly submitted will result
in expulsion from the program.
I realize the decision about acceptance into the OTA program is expected to be made by June 27, 2016.
________________________________________________________________________________
Printed Full Name
________________________________________________________________________________
Signature of Applicant
__________________________________
Date
2016 Application-11
MAKE AND KEEP A COPY OF THIS APPLICATION FORM FOR YOUR RECORDS.