BASC Certification Proposal Template

This document is a sample template to guide preparation of your certification proposal and is not intended for proposal submission. You must complete the online submission process in order for your proposal to enter the review process and be considered for presentation at the AOTA Annual Conference.

Policies Governing Accepted Proposals Please agree to the "Policies Governing Accepted Proposals" and keep a copy for your reference.

Policies Governing Accepted Proposals ☐Once a proposal is accepted as a session, changes to the proposal may not be made. ☐AOTA reserves the right to assign the day and time that accepted proposals will be scheduled. In addition, AOTA reserves the right to publish any submission, in whole or in part, in any form by any printed, visual, electronic, or auditory means. ☐All OT, OTA, and student speakers whose proposals are accepted for presentation must register for at least one day of the conference. ☐Notification will be sent by e-mail by early October 2015 regarding acceptance of proposals. Notifications not acknowledged by the due date, will result in a session being dropped from the final program. ☐The exclusive promotion or sale of goods, services, or products during educational sessions at conference is prohibited. Speakers who are found to be engaging in such practices will have their sessions halted. ☐Copyrights, Royalties, and Trademarks - Speaker warrants that no literary or artistic work or other property protected by copyright will be performed, reproduced or used, nor will the name of any entity protected by trademark be reproduced or used by Speaker during your speech and presentation (including but not limited to any exhibits, movie clips, videos, graphics) unless Speaker has obtained written permission from the copyright or trademark holder. Speaker covenants to comply strictly with all laws respecting copyright, royalties and trademarks. Speaker shall indemnify and hold AOTA, its officers, agents and employees harmless from all claims, losses and damages (including court costs and attorney fees) with respect to any such copyright, royalty or trademark rights. Visit www.copyright.com ☐If requested by AOTA, the speaker agrees to promote or discuss the conference session prior to conference. ☐Standard audiovisual equipment will be available as follows for each session except Posters & Tech Day Sessions: o 1 laptop computer w/DVD/CD player and MS Office o 1 podium and 1 head table o 1 wired podium microphone and 1 wired table microphone o 1 projection screen o 1 LCD projector o Sound system o Internet Connection o 1 laser pointer o 1 wireless floor microphone per 200 seats ☐AOTA will only reimburse Institute speakers for printed handouts. All other handouts will be posted on the Conference Web site for registered attendees to access. Instructions will be provided at a later date. ☐Presenters are expected to provide a session handout for the following session types: Pre-Conference Institute, Research Platform, Short Course, Tech Day, and Workshop. Instructions will be provided at a later date. ☐If you submit multiple submissions, you must use the same e-mail address. ☐I understand and accept the policies and deadlines for proposal submission.

*Indicates required information 1 PROPOSED SESSION TITLE

Be concise and descriptive. (Maximum character limit is 120 including spaces).

* Title of Proposed Session: Click here to enter text.

AOTA BOARD CERTIFICATION OR SPECIALTY CERTIFICATION

Do one or more of the speakers currently have AOTA Board Certification or Specialty Certification? ☐Yes ☐No

SESSION FORMAT (Predetermined)

• Workshop (Advanced-level content only): 3-hour session with reflective period for attendees with comprehensive understanding of subject matter.

LEVEL OF MATERIAL (Predetermined)

• Advanced level is geared to practitioners with a comprehensive understanding of the subject matter based on current theories and standards of practice as well as current literature and research. Focus is on recent advances and trends, and/or research applications. A high-level of participation by attendees is encouraged during this session.

CERTIFICATION AREA

For which certification area and criterion is this relevant?

Board Certification Specialty Certification ☐ BCG ☐ BCMH ☐ SCDCM ☐ SCEM ☐ SCFES ☐ BCP ☐ BCPR ☐ SCLV ☐ SCSS 1. ☐ Lifespan & Conditions – Demonstrates 1. ☐ Diagnostic Considerations – Demonstrates acquisition of current knowledge of the effects of knowledge of primary and secondary conditions the interaction between lifespan issues and that impact occupational engagement related to relevant conditions that impact occupational [certification area] performance related to [certification area] 2. ☐ Evaluation – Demonstrates knowledge of 2. ☐ Evaluation – Demonstrates acquisition of relevant evidence specific to evaluation in current knowledge of relevant evidence specific to [certification area] evaluation in [certification area] 3. ☐ Intervention – Demonstrates knowledge of 3. ☐ Intervention – Demonstrates acquisition of relevant evidence specific to intervention in current knowledge of relevant evidence specific to [certification area] intervention in [certification area] 4. ☐ Regulation & Payers – Demonstrates knowledge 4. ☐ Systems – Demonstrates acquisition of current of laws and regulations relevant to [certification knowledge of laws, regulations, payer sources, and area], including payer sources service delivery systems relevant to [certification area] *Indicates required information 2 *Indicates required information 3 PRIMARY CATAGORY

Please select a primary focus that best describes your proposal.

* Please select a primary focus:

☐ Academic & Fieldwork Education ☐ Children & Youth ☐ General & Professional Issues ☐ Health & Wellness ☐ Mental Health ☐ Productive Aging ☐ Rehabilitation, Disability, & Participation ☐ Work & Industry SECONDARY CATEGORY

Please choose the secondary focus that best describes your proposal. AOTA reserves the right to change submitter’s Secondary Category selection

* Please select a secondary category:

☐Academic Education ☐Health & Wellness ☐Advocacy ☐Home Health ☐Administration & Management ☐International & Cultural Issues ☐Chronic Conditions ☐Low Vision ☐Cognition ☐Mental Health ☐Developmental Disabilities ☐Oncology ☐Driving & Community Mobility ☐Physical Rehabilitation ☐Early Childhood ☐Primary Care ☐Environmental Modifications ☐ Private Practice ☐Feeding, Eating, & Swallowing ☐Research ☐Fieldwork Education ☐School Systems ☐General & Professional Issues ☐Sensory Integration/Sensory Processing ☐Gerontology ☐Technology ☐Hands & Upper Extremity ☐Work & Industry

SPEAKER(S) BIO

Provide a brief biography of all speakers that may appear on the mobile app.

* Maximum character limit: 400 (including spaces): Click here to enter text.

LEARNING OBJECTIVES

*Indicates required information 4 Should be specific and answer the question: "At the conclusion of this session, participants will:" Workshops may have up to 3 learning objectives. Any learning objectives above this number will not be printed.

* Objective 1: Click here to enter text.

Objective 2: Click here to enter text.

Objective 3: Click here to enter text.

ABSTRACT AND REFERENCES

The scoring of your proposal depends upon following the submission criteria closely and completely. Reviewers will use this information to score your submission.

Combined Abstract and References character count limit for session type is below:

• Workshop 3,500 (includes spaces) POINTS MAY BE DEDUCTED FOR EXCEEDING THE NOTED CHARACTER COUNTS. Note: Character count is used, NOT word count!

* Please enter Abstract and References: Click here to enter text.

ABSTRACT SYNOPSIS

Summarize the major points of your abstract and describe how this topic will advance either the practice/professional development of the participant or the field of occupational therapy. If your proposal is accepted, this information will be printed in the onsite Conference Program Guide and is subject to copy editing.

* Maximum character limit: 300 (including spaces): Click here to enter text.

CONTRIBUTING AUTHOR

Contributing authors are persons who have contributed to the development and content of the proposal but will NOT be presenting. Contributing authors will be listed in the onsite Conference Program Guide.

Include only: Full Name, Credentials. NOTE: Ensure that spelling, capitalization and credentials sequence are correct (e.g. PhD, OTR/L, FAOTA). Please do not use periods in credentials. AOTA does not recognize credentials such as “OTS” or “PhD(C),” which identifies students in pursuit of a degree not yet earned. Example Listing: William Smith, PhD, OTR/L, FAOTA; Nancy Rogers, PhD.

Please list contributing authors to this proposal: Click here to enter text.

RELIGIOUS CONFLICTS

* This session can be presented on a Saturday, no religious conflicts: ☐Yes ☐No

REPRESENTATIVE ASSEMBLY

* Are you a member of the Representative Assembly? ☐Yes ☐No

*Indicates required information 5 AOTA/AOTF SPONSORED SESSION

Enter name of AOTA/AOTF Liaison: Click here to enter text.

PRIMARY SPEAKER INFORMATION Please note: The primary speaker is the only person who will receive notifications from AOTA regarding acceptance of the proposal. The primary speaker should be a person who is either Board Certified or Specialty Certified.

ENTERING CREDENTIALS: Ensure capitalization and sequence are correct (e.g. PhD, OTR/L, FAOTA). Please do not use periods in credentials. AOTA does not recognize credentials such as “OTS” or “PhD(C),” which identifies students in pursuit of a degree not yet earned. List only the highest degree earned.

*First Name: Click here to enter text. *Last Name: Click here to enter text. Degrees/Credentials: Click here to enter text. AOTA member number: Click here to enter text. *Employer: Click here to enter text. *City: Click here to enter text. *State: Click here to enter text. Country (if outside USA): Click here to enter text. *Phone: Click here to enter text. *E-mail Address (all correspondence will be sent to this e-mail.): Click here to enter text.

ADDITIONAL AUTHOR(S) – PROVIDE INFORMATION FOR EACH ADDITIONAL AUTHOR

ADD/EDIT ADDITIONAL SPEAKER (Limit 10) This section is ONLY for information about additional speakers that will be on site presenting with you. List any contributing authors in the Session information step in the left sidebar. Contributing authors are individuals who have contributed to the proposal, but are NOT presenting with you.

1. *First Name: Click here to enter text. *Last Name: Click here to enter text. Degrees/Credentials: Click here to enter text. AOTA member number: Click here to enter text. *Employer: Click here to enter text. *City: Click here to enter text. *State: Click here to enter text. Country (if outside USA): Click here to enter text. *Phone: Click here to enter text. *E-mail Address (all correspondence will be sent to this e-mail.): Click here to enter text. 2. *First Name: Click here to enter text. *Last Name: Click here to enter text. Degrees/Credentials: Click here to enter text. AOTA member number: Click here to enter text. *Employer: Click here to enter text. *City: Click here to enter text. *State: Click here to enter text. Country (if outside USA): Click here to enter text. *Phone: Click here to enter text. *E-mail Address (all correspondence will be sent to this e-mail.): Click here to enter text.

3. *First Name: Click here to enter text. *Last Name: Click here to enter text. Degrees/Credentials: Click here to enter text. *Indicates required information 6 AOTA member number: Click here to enter text. *Employer: Click here to enter text. *City: Click here to enter text. *State: Click here to enter text. Country (if outside USA): Click here to enter text. *Phone: Click here to enter text. *E-mail Address (all correspondence will be sent to this e-mail.): Click here to enter text. 4. *First Name: Click here to enter text. *Last Name: Click here to enter text. Degrees/Credentials: Click here to enter text. AOTA member number: Click here to enter text. *Employer: Click here to enter text. *City: Click here to enter text. *State: Click here to enter text. Country (if outside USA): Click here to enter text. *Phone: Click here to enter text. *E-mail Address (all correspondence will be sent to this e-mail.): Click here to enter text. 5. *First Name: Click here to enter text. *Last Name: Click here to enter text. Degrees/Credentials: Click here to enter text. AOTA member number: Click here to enter text. *Employer: Click here to enter text. *City: Click here to enter text. *State: Click here to enter text. Country (if outside USA): Click here to enter text. *Phone: Click here to enter text. *E-mail Address (all correspondence will be sent to this e-mail.): Click here to enter text. 6. *First Name: Click here to enter text. *Last Name: Click here to enter text. Degrees/Credentials: Click here to enter text. AOTA member number: Click here to enter text. *Employer: Click here to enter text. *City: Click here to enter text. *State: Click here to enter text. Country (if outside USA): Click here to enter text. *Phone: Click here to enter text. *E-mail Address (all correspondence will be sent to this e-mail.): Click here to enter text. 7. *First Name: Click here to enter text. *Last Name: Click here to enter text. Degrees/Credentials: Click here to enter text. AOTA member number: Click here to enter text. *Employer: Click here to enter text. *City: Click here to enter text. *State: Click here to enter text. Country (if outside USA): Click here to enter text. *Phone: Click here to enter text. *E-mail Address (all correspondence will be sent to this e-mail.): Click here to enter text. 8. *First Name: Click here to enter text. *Last Name: Click here to enter text. Degrees/Credentials: Click here to enter text. AOTA member number: Click here to enter text. *Employer: Click here to enter text. *City: Click here to enter text. *State: Click here to enter text. Country (if outside USA): Click here to enter text. *Phone: Click here to enter text. *E-mail Address (all correspondence will be sent to this e-mail.): Click here to enter text. 9. *First Name: Click here to enter text. *Last Name: Click here to enter text. Degrees/Credentials: Click here to enter text. AOTA member number: Click here to enter text. *Employer: Click here to enter text. *City: Click here to enter text. *State: Click here to enter text. Country (if outside USA): Click here to enter text. *Indicates required information 7 *Phone: Click here to enter text. *E-mail Address (all correspondence will be sent to this e-mail.): Click here to enter text. 10. *First Name: Click here to enter text. *Last Name: Click here to enter text. Degrees/Credentials: Click here to enter text. AOTA member number: Click here to enter text. *Employer: Click here to enter text. *City: Click here to enter text. *State: Click here to enter text. Country (if outside USA): Click here to enter text. *Phone: Click here to enter text. *E-mail Address (all correspondence will be sent to this e-mail.): Click here to enter text.

*Indicates required information 8