Health Occupations Program
Attn: OT Licensing
P.O. Box 64882
Saint Paul, MN 55164-0882
Fax: 651-201-3839
Email: [email protected]
Minnesota Department of Health
Health Occupations Program
Occupational Therapy Practitioner
Continuing Education Record
For MDH Office use only
NAME: _________________________________________________________ OT LICENSE #: _______________________
ADDRESS: _____________________________ CITY: ____________________ STATE: _____ ZIP CODE: ______________
DAYTIME PHONE NUMBER (________)_____________________
TITLE OF WORKSHOP, PRESENTATION, SEMINAR OR OTHER
NAME OF PRESENTER, SPONSOR OR DESIGNEE*
ATTENDANCE
DATE(S)
(MM/DD/YY)**
CONTACT
HOURS
The above information is true and correct to the best of my knowledge and belief.
Signature__________________________________________________ Date signed_________________________________
(Must be signed and dated within 30 days of submitting)
* Please do not send in certificates of attendance or course completion, but keep them for your records in the event you are audited.
** Courses reported must have been attended between the effective and expiration dates of the license.
NOTE: You may scan and email your Continuing Education (CE) form to our office. Keep a copy of the email that you sent for your records.
You may fax your CE form, keep a copy of the fax confirmation for your records.
TITLE OF WORKSHOP, PRESENTATION, SEMINAR OR OTHER
NAME OF PRESENTER, SPONSOR OR DESIGNEE*
ATTENDANCE
DATE(S)
(MM/DD/YY)**
CONTACT
HOURS
The above information is true and correct to the best of my knowledge and belief.
Signature_________________________________________________________ Date signed_________________________________
(Must be signed and dated within 30 days of submitting)
* Please do not send in certificates of attendance or course completion, but keep them for your records in the event you are audited.
** Courses reported must have been attended between the effective and expiration dates of the license.
NOTE: You may scan and email your Continuing Education (CE) form to our office. Keep a copy of the email that you sent for your records.
You may fax your CE form, keep a copy of the fax confirmation for your records.
L:\HOP\CREDENTIAL\OT\CONT_EDU\final 8_25_2015 OT cercdfrm.doc
Updated 08/20/2015