Stage 2 Application for Supervised Practice Please read the Stage 2 Guidelines to assist with completion of this documentation
PLEASE PRINT Please complete all sections and attach relevant documents
Section A: Personal Details
Family name
Given name(s)
Any previous names (eg. prior to marriage)
Gender Male Female Day Month Year Date of birth
AHPRA Registration No.
Address for correspondence
Telephone Fax
e-mail Contact details – please provide private and Telephone Fax business details, and write your email address clearly e-mail
Mobile:
Date of OTC Stage 1 Assessment Letter Date of Award Qualifications
Stage 2 – Application for Supervised Practice Page 1 of 6 Revised October 2014 Country Awarding Institution
Note: A short resume of your experience in the practice of occupational therapy MUST accompany your application. The resume should include dates where your experience was gained and the areas of experience.
Section B: Employer’s Details
Name of employing agency
Address of employing agency
Position for supervised practice audit
Commencement date of Day Month Year supervised practice audit Hours of work per week for period of supervised practice audit Anticipated completion date for supervised Day Month Year practice audit
Summary of services offered by employing agency
Note: Please attach copy of your Job Description
Stage 2 – Application for Supervised Practice Page 2 of 6 Revised October 2014 Section C: Details of Supervisor(s) If two supervisors have been nominated and approved for the period of supervised practice, the supervisors must confer regarding the practitioner’s progress prior to the completion of any assessment report. It is not appropriate for the practitioner to provide communication between two supervisors.
Name
Position
Place of work Primary occupational therapist supervisor Contact details (telephone and email)
AHPRA Registration no.
Qualification (name, institution and conferral date):
Name
Position
Place of work Secondary occupational therapist supervisor (if Contact details (telephone and email) required)
AHPRA Registration no.
Qualification (name, institution and conferral date):
NOTE: Please include a curriculum vitae for each supervisor. If a third supervisor is required, please attach as a separate document, including all information above.
Section C: Practice Audit Details – if space is insufficient please attach separate document
NOTE: Please maintain a signed log of supervision received during the period of supervised practice
As a minimum weekly face-to-face supervision (one hour per week) for the first six weeks, thereafter it could be modified to at least fortnightly until completion. Weekly for the first six weeks
Thereafter: Details of formal Face-to-face – specify frequency ……………………………………….. supervision with occupational therapy Telephone – specify frequency …………………………………………. supervisor Other – specify frequency ……………………………………………….
……………………………………………………………………………
Stage 2 – Application for Supervised Practice Page 3 of 6 Revised October 2014 Supervised practice audit Please complete and attach your learning goals, aims and how these are to be learning goals prepared in measured in the preferred format. conjunction with supervisor(s)
Description of the types of clients with whom you will work.
Description of the types of OT services you will provide eg. prescription of equipment, referral and liaison with community agencies, group work, work site visits, home visits, splinting etc.
Describe the range of skills and interventions to be undertaken eg. assessment using specific tools or protocols, planning individual programs, provision of services to individuals or groups, evaluation of care, report writing, communication with clients and others professionals.
Describe any other professional experiences that will be gained eg. specific quality activities, research, administrative duties etc
Stage 2 – Application for Supervised Practice Page 4 of 6 Revised October 2014 Detail the self-directed learning goals you will undertake to meet your learning goals. These would typically be activities you would undertake by yourself to gather information and learn about current or local issues of practice
Details of performance appraisal to be undertaken.
Signature of practitioner Date
Date Signature of supervisor
Checklist
Please ensure the following attachments are included with your application
Practitioner’s curriculum vitae.
Practitioner’s job description for supervised practice audit.
Supervisor’s curriculum vitae. If more than one supervisor, please provide a curriculum vitae for each one.
Learning goals in preferred format, identified appropriately, and signed by you and your supervisor.
Any additional documents related to the supervised practice audit.
Application fee.
Fees
The fee must accompany this application form and made payable to OTC in Australian dollars by one of the following methods:
A money order issued by Australia Post. Credit card – form available on the website and should accompany this application. A bank cheque drawn by an Australian bank. A personal cheque drawn on an Australian bank account. Foreign bank draft in Australian dollars and drawn on an Australian bank. Stage 2 – Application for Supervised Practice Page 5 of 6 Revised October 2014 Direct debit as follows:
Account name: Occupational Therapy Council Bank: Westpac BSB: 036 308 Account no.: 28 2504 International Swift: WPACAU2S
Please ensure your name appears on the statement of the OTC, and you advise us via email that payment has been effected.
Please do not send your payment of fees in cash by post.
A receipt will be issued to acknowledge OTC has received your application and fee. The fee is not refundable.
Section D: Statement of Privacy
The Occupational Therapy Council (Australia & New Zealand) Ltd (OTC) is required to observe the provisions of the Commonwealth Privacy Amendment (Private Sector) Act 2000, which has effect from 21 December 2001 and sets out the requirements for the collection and use of personal information collected before and after that date.
As from 21 December 2001 each of the Application Forms used by the OTC is required to include a statement relating to the OTC’s privacy procedures. Each must be signed by the practitioner to give formal consent for the OTC to collect and hold personal information.
If consent is not provided, the OTC will not be able to process your application.
You MUST sign one of these consent forms for every application form you are submitting to the OTC.
Your privacy is respected by the OTC. Information collected by the OTC may be used for administering the assessment process and provided to OTC and the Overseas Qualifications Assessment Committee (OQAC), members of the Australian Health Practitioner Regulation Agency (AHPRA), The Occupational Therapy Board of Australia (OBTA), Occupational Therapists Registration Board of New Zealand (OTBNZ) and OT Australia (National and State Associations).
The OTC privacy procedures are set out in a Policy Statement which can be obtained from the OTC or its website www.otcouncil.com.au If you have any privacy concerns or would like to verify information held about you please contact the OTC, PO Box 959, South Perth WA 6951
Consent to Collect Information:
Full name: ………………………………………………………….
Signature:...... Date:......
POST YOUR APPLICATION TO:
Occupational Therapy Council (Australia & New Zealand) Ltd PO Box 959 South Perth WA 6951
Stage 2 – Application for Supervised Practice Page 6 of 6 Revised October 2014