Table of Contents: ACTIVITY EVIDENCE FORMS

GERONTOLOGY BOARD CERTIFICATION Table of Contents: ACTIVITY EVIDENCE FORMS Instructions:  Please complete 1 form for each criterion. Combine completed forms in a single document (e.g., Word or .PDF) and e-mail with the completed application to [email protected].  Please do not include unused forms.

Criterion 1: Knowledge: Lifespan & Conditions Criterion 7: Intervention: Design &  Formal Learning Implementation  Independent Learning  Client-Based Case Study  Mentee  Formal Specialized Consultation for  Publication – Peer-Reviewed Intervention  Mentee Criterion 2: Knowledge: Evaluation  Program Development  Formal Learning  Research  Independent Learning  Self-Analysis of Video Recording  Mentee  Publication – Peer-Reviewed Criterion 8: Intervention: Wellness & Prevention

Criterion 3: Knowledge: Intervention  Client-Based Case Study  Formal Learning  Formal Specialized Consultation for  Independent Learning Intervention  Mentee  Mentee  Publication – Peer-Reviewed  Self-Analysis of Video Recording

Criterion 4: Knowledge: Systems Criterion 9: Outcomes

 Formal Learning  Formal Specialized Consultation for Outcomes  Independent Learning  Program/Service Evaluation  Mentee  Research  Publication – Peer-Reviewed Criterion 10: Holistic Practice Criterion 5: Evaluation: Uses Relevant Evidence  Holistic Practice Case Study

 Client-Based Case Study Criterion 11: Ethical Practice – The 3  Program Development ethical practice scenarios are found within  Research the application itself.  Self-Analysis of Video Recording Criterion 12: Advocating for Change Criterion 6: Evaluation: Prioritizes Needs  Advocacy Case Study  Client-Based Case Study  Advocacy Efforts  Program Development  Volunteer Leadership  Research

© 2017 The American Occupational Therapy Association, Inc. All rights reserved. FORMAL LEARNING Table of Contents Criterion 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 gerontology.

Guidelines  Minimum of 10 contact hours required.  Multiple activities may be used to meet the hour requirement for the criterion.  Learning must have occurred in the past 5 years.

Please identify the type of activity in which you participated:

☐ AOTA CE: Participation in Self-Paced Clinical Course or CE Product from the list of AOTA offerings approved for this certification. Completion of course will be verified by AOTA. Submission of additional documentation beyond this form not required.

☐ Non-AOTA CE: Attending workshops, seminars, lectures, or professional conferences with formal established objectives.

☐ Participation in post-professional academic coursework. Attach unofficial transcript.

1. Activity information.

Activity Title

Provider/Instructor

Activity Date(s)

No. of Contact Hours

2. Activity Learning Objectives. List up to 5. A)

E) 3. Describe the relevance of the activity to your practice in gerontology. (average word guideline–200) 4.

5. 6. 7. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to gerontology.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200) 8.

9. 10. Submit documentation that verifies completion of the activity, such as certificate of completion or unofficial transcript. Not required for AOTA courses. 11. 12. 13. INDEPENDENT LEARNING 14. Table of Contents 15. Criterion 1–Knowledge: Lifespan & Conditions 16. Demonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to gerontology.

17. 18. Guidelines  Minimum of 10 contact hours required.  Multiple activities may be used to meet the hour requirement for the criterion.  Learning must have occurred in the past 5 years. 19. 20. Please identify the type of independent learning activity in which you participated:

21. ☐ Independent reading from AOTA-Approved Independent Learning List in gerontology. 22. ☐ Independent reading of recent peer-reviewed, professional articles, or chapters in textbook not associated with a formal learning course. 23. ☐ Independent review of professional electronic resources (e.g., NIH, CDC, CanChild). 24. ☐ AOTA Journal Club Toolkit (reading & discussion time). Must be AOTA member to access the kit. 25. ☐ AOTA Critically Appraised Paper (CAP, includes submission to the AOTA Evidence Exchange). 26. 1. Why did you choose this activity?

27. ☐ Clinical reference for specific population, program, or individual 28. ☐ Invited peer review of scholarly work or publication (print or online) 29. ☐ Preparation for poster or presentation 30. ☐ Preparation for academic lecture 31. ☐ Literature review for research project 32. ☐ Preparation for serving as a mentor 33. ☐ Other, please specify: ______34. 2. Bibliography of select item(s) used for independent learning. List in APA format. 35.

36. 3. Date(s) of independent learning 37.

38. 4. Time spent engaged in independent learning.  For reading, estimate 8–12 published pages/hour. Not required for AOTA-identified independent learning list of resources.  For journal club, discussion time counts toward 10-hour requirement. 39. 40. 5. Describe the relevance of the independent learning activity to your practice in gerontology. (average word guideline–200) 6.

7. 8. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to gerontology.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200) 9.

10. 11. MENTORING RELATIONSHIP–MENTEE 12. Table of Contents 13. Criterion 1–Knowledge: Lifespan & Conditions 14. Demonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to gerontology.

15. 16. Guidelines  Must represent a minimum of 10 hours over a minimum of 2 months.  Does not include supervisory relationships.  Relationship must have occurred in the past 5 years. 17. 1. Dates of mentoring relationship 18. 19. 20. 2. Approximately how many hours did this represent in total? 21. 22. 23. 3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application. List no more than 3. 24. A)

25. 26. 4. 28. 27. Mentor 30. 29. Position/Role of Mentor 32. 31. Workplace of Mentor 33. Contact Information for 34. Mentor (email or phone number) 35. 36. 5. State why the mentor was selected to help you meet the goals identified above relative to the criterion. (average word guideline–50) 37.

38. 39. 6. Briefly describe how the skills acquired from this mentoring activity influenced your service delivery with clients, specific to your ability to “demonstrate acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to gerontology.” (average word guideline–350) 40. 41. PUBLICATION – PEER-REVIEWED 42. Table of Contents 43. Criterion 1–Knowledge: Lifespan & Conditions 44. Demonstrates acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to gerontology.

45. 46. Guidelines  Examples of peer-reviewed publication include journals such as AJOT or OTJR.  May include a chapter in an occupational therapy or related professional textbook, if chapter has gone through peer review (a process in which subject matter experts, using a formal system and defined guidelines, provide content guidance to an author and recommend publication, revision, or rejection of a work). 47. 48. 1. Submit APA reference for the publication. For in-press publication, also include a verification letter or e-mail identifying applicant and anticipated date of publication. 49.

50. 51. 2. If applicant is not identified as first or second author, please describe your contribution/involvement in the development of the publication. (average word guideline–200) 52.

53. 3. Provide a reflection indicating why this publication was chosen to represent “acquisition of current knowledge of the effects of the interaction between lifespan issues and relevant conditions that impact occupational performance related to gerontology” and how it influenced your practice. (average word guideline–200) 54. 55. FORMAL LEARNING 56. Table of Contents 57. 58. Criterion 2–Knowledge: Evaluation 59. Demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in gerontology. 60. 61. 62. Guidelines  Minimum of 10 contact hours required.  Multiple activities may be used to meet the hour requirement for the criterion.  Learning must have occurred in the past 5 years. 63. 64. Please identify the type of activity in which you participated:

65. ☐ AOTA CE: Participation in Self-Paced Clinical Course or CE Product from the list of AOTA offerings approved for this certification. Completion of course will be verified by AOTA. Submission of additional documentation beyond this form not required.

66. ☐ Non-AOTA CE: Attending workshops, seminars, lectures, or professional conferences with formal established objectives.

67. ☐ Participation in post-professional academic coursework. Attach unofficial transcript. 68. 1. Activity information. 69. 71. 70. Activity Title 73. 72. Provider/Instructor 75. 74. Activity Date(s) 76. No. of Contact 77. Hours 78. 2. Activity Learning Objectives. List up to 5. A)

79. 3. Describe the relevance of the activity to your practice in gerontology. (average word guideline–200) 4.

5. 6. 7. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in gerontology.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200) 8.

9. 10. Submit documentation that verifies completion of the activity, such as certificate of completion or unofficial transcript. Not required for AOTA courses. 11. 12. INDEPENDENT LEARNING 13. Table of Contents 14. 15. Criterion 2–Knowledge: Evaluation 16. Demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in gerontology. 17. 18. 19. Guidelines  Minimum of 10 contact hours required.  Multiple activities may be used to meet the hour requirement for the criterion.  Learning must have occurred in the past 5 years. 20. 21. Please identify the type of independent learning activity in which you participated:

7. 8. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in gerontology.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200) 9. 10. MENTORING RELATIONSHIP–MENTEE 11. Table of Contents 12. Criterion 2–Knowledge: Evaluation 13. Demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in gerontology.

24. 25. 4. 27. 26. Mentor 29. 28. Position/Role of Mentor 31. 30. Workplace of Mentor 32. Contact Information for 33. Mentor (email or phone number) 34. 35. 5. State why the mentor was selected to help you meet the goals identified above relative to the criterion. (average word guideline–50) 36. 37. 38. 6. Briefly describe how the skills acquired from this mentoring activity influenced your service delivery with clients, specific to your ability to “demonstrate acquisition of current knowledge of relevant evidence specific to evaluation in gerontology.” (average word guideline–350) 39.

40. 41. PUBLICATION – PEER-REVIEWED 42. Table of Contents 43. 44. Criterion 2–Knowledge: Evaluation 45. Demonstrates acquisition of current knowledge of relevant evidence specific to evaluation in gerontology. 46. 47. 48. Guidelines  Examples of peer-reviewed publication include journals such as AJOT or OTJR.  May include a chapter in an occupational therapy or related professional textbook, if chapter has gone through peer review (a process in which subject matter experts, using a formal system and defined guidelines, provide content guidance to an author and recommend publication, revision, or rejection of a work). 49. 50. 1. Submit APA reference for the publication. For in-press publication, also include a verification letter or e-mail identifying applicant and anticipated date of publication. 51.

55. 3. Provide a reflection indicating why this publication was chosen to represent “acquisition of current knowledge of relevant evidence specific to evaluation in gerontology” and how it influenced your practice. (average word guideline–200) 56.

57. 58. 59. FORMAL LEARNING 60. Table of Contents 61. 62. Criterion 3–Knowledge: Intervention 63. Demonstrates acquisition of current knowledge of relevant evidence specific to intervention in gerontology. 64. 65. 66. Guidelines  Minimum of 10 contact hours required.  Multiple activities may be used to meet the hour requirement for the criterion.  Learning must have occurred in the past 5 years. 67. 68. Please identify the type of activity in which you participated:

5. 6. 7. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of relevant evidence specific to intervention in gerontology.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200) 8.

9. 10. Submit documentation that verifies completion of the activity, such as certificate of completion or unofficial transcript. Not required for AOTA courses. 11. INDEPENDENT LEARNING 12. Table of Contents 13. 14. Criterion 3–Knowledge: Intervention 15. Demonstrates acquisition of current knowledge of relevant evidence specific to intervention in gerontology. 16. 17. 18. Guidelines  Minimum of 10 contact hours required.  Multiple activities may be used to meet the hour requirement for the criterion.  Learning must have occurred in the past 5 years. 19. 20. Please identify the type of independent learning activity in which you participated:

7. 8. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of relevant evidence specific to intervention in gerontology.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200) 9. 10. MENTORING RELATIONSHIP–MENTEE 11. Table of Contents 12. Criterion 3–Knowledge: Intervention 13. Demonstrates acquisition of current knowledge of relevant evidence specific to intervention in gerontology.

24. 25. 4. 27. 26. Mentor 29. 28. Position/Role of Mentor 31. 30. Workplace of Mentor 32. Contact Information for 33. Mentor (email or phone number) 34. 35. 5. State why the mentor was selected to help you meet the goals identified above relative to the criterion specified. (average word guideline–50) 36. 37. 38. 6. Briefly describe how the skills acquired from this mentoring activity influenced your service delivery with clients, specific to your ability to “demonstrate acquisition of current knowledge of relevant evidence specific to intervention in gerontology.” (average word guideline–350) 39.

40. 41. PUBLICATION – PEER-REVIEWED 42. Table of Contents 43. 44. Criterion 3–Knowledge: Intervention 45. Demonstrates acquisition of current knowledge of relevant evidence specific to intervention in gerontology. 46. 47. 48. Guidelines  Examples of peer-reviewed publication include journals such as AJOT or OTJR.  May include a chapter in an occupational therapy or related professional textbook, if chapter has gone through peer review (a process in which subject matter experts, using a formal system and defined guidelines, provide content guidance to an author and recommend publication, revision, or rejection of a work). 49. 50. 1. Submit APA reference for the publication. For in-press publication, also include a verification letter or e-mail identifying applicant and anticipated date of publication. 51.

55. 3. Provide a reflection indicating why this publication was chosen to represent “acquisition of current knowledge of relevant evidence specific to intervention in gerontology” and how it influenced your practice. (average word guideline–200) 56.

57. 58. 59. FORMAL LEARNING 60. Table of Contents 61. 62. Criterion 4–Knowledge: Systems 63. Demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to gerontology. 64. 65. 66. Guidelines  Minimum of 3 contact hours required.  Multiple activities may be used to meet the hour requirement for the criterion.  Learning must have occurred in the past 5 years. 67. 68. Please identify the type of activity in which you participated:

5. 6. 7. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to gerontology.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200) 8.

9. 10. Submit documentation that verifies completion of the activity, such as certificate of completion or unofficial transcript. Not required for AOTA courses. 11. 12. INDEPENDENT LEARNING 13. Table of Contents 14. 15. Criterion 4–Knowledge: Systems 16. Demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to gerontology. 17. 18. 19. Guidelines  Minimum of 3 contact hours required.  Multiple activities may be used to meet the hour requirement for the criterion.  Learning must have occurred in the past 5 years. 20. 21. Please identify the type of independent learning activity in which you participated:

7. 8. Describe how the knowledge acquired from this activity “demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to gerontology.” How did the activity influence the way you practice, or how did it affect your client outcomes? (average word guideline–200) 9.

10. 11. MENTORING RELATIONSHIP–MENTEE 12. Table of Contents 13. Criterion 4–Knowledge: Systems 14. Demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to gerontology.

25. 26. 4. 28. 27. Mentor 30. 29. Position/Role of Mentor 32. 31. Workplace of Mentor 33. Contact Information for 34. Mentor (email or phone number) 35. 36. 5. State why the mentor was selected to help you meet the goals identified above relative to the criterion. (average word guideline–50) 37. 38. 39. 6. Briefly describe how the skills acquired from this mentoring activity influenced your service delivery with clients, specific to your ability to “demonstrate acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to gerontology.” (average word guideline–350) 40.

41. 42. PUBLICATION – PEER-REVIEWED 43. Table of Contents 44. 45. Criterion 4–Knowledge: Systems 46. Demonstrates acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to gerontology. 47. 48. 49. Guidelines  Examples of peer-reviewed publication include journals such as AJOT or OTJR.  May include a chapter in an occupational therapy or related professional textbook, if chapter has gone through peer review (a process in which subject matter experts, using a formal system and defined guidelines, provide content guidance to an author and recommend publication, revision, or rejection of a work). 50. 51. 1. Submit APA reference for the publication. For in-press publication, also include a verification letter or e- mail identifying applicant and anticipated date of publication. 52.

56. 3. Provide a reflection indicating why this publication was chosen to represent “acquisition of current knowledge of laws, regulations, payer sources, and service delivery systems relevant to gerontology” and how it influenced your practice. (average word guideline–200) 57.

58. 59. CLIENT-BASED CASE STUDY 60. Table of Contents 61. 62. Criterion 5–Evaluation: Uses Relevant Evidence 63. Uses relevant evidence to establish an occupational profile with the client (person, organization, population) and assess the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.

64. 65. Guidelines  Client-based case study should not include any form of standard client documentation (e.g., evaluation summary, discharge plan) or identification of client name(s) or facility information.

66. 67. 1. Date(s) case study represents. 68. 69. 2. Describe the client, client factors, and case contexts for the identified case. The context of the case should be adequately communicated so that relevance and merit of the case to the criterion is easily determined. (average word guideline–500) 70. 71. 72. 73. 3. Articulate how this case demonstrates how you used “relevant evidence to establish an occupational profile with the client (person, organization, population) and assess the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.” (average word guideline–500) 74. 75. 76. PROGRAM DEVELOPMENT 77. Table of Contents 78. 79. Criterion 5–Evaluation: Uses Relevant Evidence 80. Uses relevant evidence to establish an occupational profile with the client (person, organization, population) and assess the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate. 81. Guidelines  Program development refers to the creation of a new program or development of an evolving program.

1. Dates of program development 82.

83. 2. Briefly describe the program purpose, services offered, and clients served. (average word guideline– 250) 84.

85. 3. Describe how this program development activity, including description of resources used, demonstrates your use of “relevant evidence to establish an occupational profile with the client (person, organization, population) and assess the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.” (average word guideline–500) 86. 87. RESEARCH 88. Table of Contents 89. 90. Criterion 5–Evaluation: Uses Relevant Evidence 91. Uses relevant evidence to establish an occupational profile with the client (person, organization, population) and assess the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.

92. 93. What type of research was conducted? Please choose 1.

94. ☐ Scientific inquiry–Qualitative, quantitative, or mixed-methods approach.

95. ☐ Methodological research/instrument development–Scientific inquiry to establish psychometric properties of (1) a new tool, (2) an existing tool with a new population, or (3) an existing tool translated to a new language.

96. ☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing literature to answer a focused question. 97. 1. Title of research conducted. 98.

99. 2. Mechanism of dissemination:

100. ☐ Publication

101. ☐ Peer-reviewed presentation

102. ☐ Grant funding

103. ☐ Critically Appraised Topic (CAT, e.g., AOTA Evidence-Based Practice Project Web site)

104. ☐ Dissertation/thesis 105. Citation: (average word guideline–25) 106.

107. 3. Role of applicant in the research. (average word guideline–25) 108. 109.

110. 4. Purpose and rationale of the research. (average word guideline–200) 5. 6.

7. 8. 9. Describe how this research demonstrates your use of “relevant evidence to establish an occupational profile with the client (person, organization, population) and assess the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.” (average word guideline–400) 10. 11. 12. SELF-ANALYSIS OF VIDEO RECORDING 13. Table of Contents 14. 15. Criterion 5–Evaluation: Uses Relevant Evidence 16. Uses relevant evidence to establish an occupational profile with the client (person, organization, population) and assess the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.

17. 18. Guidelines  Submission of actual video recording is not required for application; however, appropriate permissions should be obtained by applicant whenever engaging a client in a video-taped session. 19. 1. 21. 20. Age of Client 22. Client 23. Diagnosis(es) 24. Setting for 25. Evaluation 26. Date of Video 27. Recording 28. 29. 2. Provide a brief summary of the video content and how it demonstrates your use of “relevant evidence to establish an occupational profile with the client (person, organization, population) and assess the client’s occupational performance through a variety of measures, including standardized assessments, as appropriate.” (average word guideline–200) 30. 31.

32. 3. After reviewing this video, describe the insights you gained, and reflect on how the analysis experience validated or supported change in your evaluation practice. (average word guideline–400) 4. 5. 6. CLIENT-BASED CASE STUDY 7. Table of Contents 8. 9. Criterion 6–Evaluation: Prioritizes Needs 10. Prioritizes needs related to the client, context, and performance by synthesizing and interpreting assessment data and clinical observations in gerontology.

13. 14. 1. Date(s) case study represents. 15. 16. 2. Describe the client, client factors, and case contexts for the identified case. The context of the case should be adequately communicated so that relevance and merit of the case to the criterion is easily determined. (average word guideline–500) 17. 18. 19. 20. 3. Articulate how this case demonstrates how you “prioritized needs related to the client, context, and performance by synthesizing and interpreting assessment data and clinical observations in gerontology.” (average word guideline–500) 21. 22. 23. PROGRAM DEVELOPMENT 24. Table of Contents 25. 26. Criterion 6–Evaluation: Prioritizes Needs 27. Prioritizes needs related to the client, context, and performance by synthesizing and interpreting assessment data and clinical observations in gerontology.

28. 29. Guidelines  Program development refers to the creation of a new program or development of an evolving program.

1. Dates of program development 30.

31. 2. Briefly describe the program purpose, services offered, and clients served. (average word guideline– 250) 32.

33. 3. Describe how this program development activity demonstrates how you “prioritize needs related to the client, context, and performance by synthesizing and interpreting assessment data and clinical observations in gerontology.” (average word guideline–500) 34. 35. RESEARCH 36. Table of Contents 37. 38. Criterion 6–Evaluation: Prioritizes Needs 39. Prioritizes needs related to the client, context, and performance by synthesizing and interpreting assessment data and clinical observations in gerontology.

48. ☐ Publication

3. 4. 5. Describe how this research demonstrates your ability to “prioritize needs related to the client, context, and performance by synthesizing and interpreting assessment data and clinical observations in gerontology.” (average word guideline–400) 5. 6. 7. CLIENT-BASED CASE STUDY 8. Table of Contents 9. 10. Criterion 7–Intervention: Design & Implementation 11. Designs and implements gerontology interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

14. 15. 1. Date(s) case study represents. 16. 17. 2. Describe the client, client factors, and case contexts for the identified case. The context of the case should be adequately communicated so that relevance and merit of the case to the criterion is easily determined. (average word guideline–500) 18. 19.

20. 3. Articulate how this case demonstrates your ability to “design and implement gerontology interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average word guideline–500) 21. 22. 23. FORMAL SPECIALIZED CONSULTATION FOR INTERVENTION 24. Table of Contents 25. 26. Criterion 7–Intervention: Design & Implementation 27. Designs and implements gerontology interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

28. 29. Guidelines  This should not be confused with consultation that is part of the ongoing services provided in your routine job duties but is a request to address a particular issue at a particular site, either external or internal.  Consultation may include (but is not limited to) developing or evaluating a program or service, developing a strategy for long-term planning, establishing outcomes measures, incorporating national guidelines into internal policies and procedures, assessing and addressing staff educational needs, assessing and addressing resource needs, and validating program/service delivery with current evidence.  Applicant must have had a minimum of 10 hours working with the site. 30. 1. 31. Entity for Which 32. Consultation Was Completed 33. Date(s) of 34. Consultation 35. No. of Hours 36. Completed During Consultation 37. 2. Objectives for consultation. Objectives must have been met by time of application. Please list no more than 3. A)

38. 3. Summarize the consultation results. (average word guideline–200) 39.

40. 4. Summarize how this professional development activity influenced your ability to “design and implement gerontology interventions that are client-centered, contextually relevant, and evidence- based to facilitate optimal occupational engagement.” (average word guideline–400) 41. 42. 43. MENTORING RELATIONSHIP–MENTEE 44. Table of Contents 45. 46. Criterion 7–Intervention: Design & Implementation 47. Designs and implements gerontology interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

48. 49. Guidelines  Must represent a minimum of 10 hours over a minimum of 2 months.  Does not include supervisory relationships.  Relationship must have occurred in the past 5 years. 50. 1. Dates of mentoring relationship 51. 52. 2. Approximately how many hours did this represent in total? 53. 54. 3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application. List no more than 3. 55. A)

56. 4. 58. 57. Mentor 60. 59. Position/Role of Mentor 62. 61. Workplace of Mentor 63. Contact Information for 64. Mentor (email or phone number) 65. 66. 5. State why the mentor was selected to help you meet the goals identified above relative to the criterion specified. (average word guideline–50) 67. 68. 69. 6. Briefly describe how the skills acquired from this mentoring activity influenced your service delivery with clients, specific to your ability to “design and implement gerontology interventions that are client- centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average word guideline–350) 7. 8. 9. PROGRAM DEVELOPMENT 10. Table of Contents 11. 12. Criterion 7–Intervention: Design & Implementation 13. Designs and implements gerontology interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

14. 15. Guidelines  Program development refers to the creation of a new or development of an evolving program. 16. 1. Dates of program development. 17. 18. 2. Briefly describe the program purpose, services offered, and clients served. (average word guideline– 250) 19. 20.

21. 3. Describe how this program development activity, including description of resources used, demonstrates your ability to “design and implement gerontology interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average word guideline–500) 22. 23. 24. RESEARCH 25. Table of Contents 26. 27. Criterion 7–Intervention: Design & Implementation 28. Designs and implements gerontology interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

37. ☐ Publication

7. 8. 9. 10. Describe how this research demonstrates your ability to “design and implement gerontology interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.” (average word guideline–400) 11. 12. 13. SELF-ANALYSIS OF VIDEO RECORDING 14. Table of Contents 15. 16. Criterion 7–Intervention: Design & Implementation 17. Designs and implements gerontology interventions that are client-centered, contextually relevant, and evidence-based to facilitate optimal occupational engagement.

18. 19. Guidelines  Submission of actual video recording is not required for application; however, appropriate permissions should be obtained by applicant whenever engaging a client in a video-taped session. 20. 1. 22. 21. Age of Client 23. Client 24. Diagnosis(es) 25. Setting for 26. Evaluation 27. Date of Video 28. Recording 29. 30. 2. Provide a brief summary of the video contents and how it demonstrates your ability to “design and implement gerontology interventions that are client-centered, contextually relevant, and evidence- based to facilitate optimal occupational engagement.” (average word guideline–200) 31. 32.

33. 34. 3. After reviewing this video, describe the insights you gained, and reflect on how the analysis experience validated or supported change in your intervention practice. (average word guideline–400) 4. 5. 6. CLIENT-BASED CASE STUDY 7. Table of Contents 8. 9. Criterion 8–Intervention: Wellness & Prevention 10. Provides gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

13. 14. 1. Date(s) case study represents. 15. 2. Describe the client, client factors, and case contexts for the identified case. The context of the case should be adequately communicated so that relevance and merit of the case to the criterion is easily determined. (average word guideline–500) 16.

3. Articulate how this case demonstrates your ability to “provide gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–500) 17. 18. 19. FORMAL SPECIALIZED CONSULTATION FOR INTERVENTION 20. Table of Contents 21. 22. Criterion 8–Intervention: Wellness & Prevention 23. Provides gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

24. 25. Guidelines  This should not be confused with consultation that is part of the ongoing services provided in your routine job duties but is a request to address a particular issue at a particular site, either external or internal.  Consultation may include (but is not limited to) developing or evaluating a program or service, developing a strategy for long-term planning, establishing outcomes measures, incorporating national guidelines into internal policies and procedures, assessing and addressing staff educational needs, assessing and addressing resource needs, and validating program/service delivery with current evidence.  Applicant must have had a minimum of 10 hours working with the site. 26. 1. 27. Entity for Which 28. Consultation Was Completed 30. 29. Date(s) of Consultation 31. No. of Hours Completed 32. During Consultation 33. 2. Objectives for consultation. Objectives must have been met by time of application. Please list no more than 3. A)

34. 3. Summarize the consultation results. (average word guideline–200) 35. 36. 4. Summarize how this professional development activity influenced your ability to “provide gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–400) 37. 38. 39. MENTORING RELATIONSHIP–MENTEE 40. Table of Contents 41. 42. Criterion 8–Intervention: Wellness & Prevention 43. Provides gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

44. 45. Guidelines  Must represent a minimum of 10 hours over a minimum of 2 months.  Does not include supervisory relationships.  Relationship must have occurred in the past 5 years. 46. 1. Dates of mentoring relationship 47. 48. 2. Approximately how many hours did this represent in total? 49. 50. 3. Applicant’s goals for mentoring relationship. Goals must have been met by time of application. List no more than 3. 51. A)

52. 4. 54. 53. Mentor 56. 55. Position/Role of Mentor 58. 57. Workplace of Mentor 59. Contact Information for 60. Mentor (email or phone number) 61. 62. 5. State why the mentor was selected to help you meet the goals identified above relative to the criterion specified. (average word guideline–50) 63. 64. 65. 6. Briefly describe how the skills acquired from this mentoring activity influenced your service delivery with clients, specific to your ability to “provide gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–350) 1. 2. 3. PROGRAM DEVELOPMENT 4. Table of Contents 5. 6. Criterion 8–Intervention: Wellness & Prevention 7. Provides gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

8. 9. Guidelines  Program development refers to the creation of a new or development of an evolving program. 10. 1. Dates of program development. 11. 12. 2. Briefly describe the program purpose, services offered, and clients served. (average word guideline– 250) 13. 14.

15. 16. 3. Describe how this program development activity, including description of resources used, demonstrates your ability to “provide gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–500) 4. 5.

6. 7. 8. RESEARCH 9. Table of Contents 10. 11. Criterion 8–Intervention: Wellness & Prevention 12. Provides gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

21. ☐ Publication

31. 32. 4. Purpose and rationale of the research. (average word guideline–250) 5. 6.

7. 8. Describe how this research demonstrates your ability to “provide gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–400) 9. 10.

11. 12. SELF-ANALYSIS OF VIDEO RECORDING 13. Table of Contents 14. 15. Criterion 8–Intervention: Wellness & Prevention 16. Provides gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.

17. 18. Guidelines  Submission of actual video recording is not required for application; however, appropriate permissions should be obtained by applicant whenever engaging a client in a video-taped session. 19. 1. 21. 20. Age of Client 22. Client 23. Diagnosis(es) 24. Setting for 25. Evaluation 26. Date of Video 27. Recording 28. 29. 2. Provide a brief summary of the video contents and how it demonstrates your ability to “provide gerontology intervention that incorporates wellness and prevention for clients (persons, organizations, populations) to optimize present and future occupational engagement.” (average word guideline–200) 30. 31.

32. 3. After reviewing this video, describe the insights you gained, and reflect on how the analysis experience validated or supported change in your intervention practice. (average word guideline–400) 4. 5.

6. 7. FORMAL SPECIALIZED CONSULTATION FOR OUTCOMES 8. Table of Contents 9. 10. Criterion 9–Outcomes 11. Evaluates effectiveness of services delivered, either for caseload or programs, in order to validate service delivery and make changes as appropriate to maximize outcomes related to gerontology.

12. 13. Guidelines  This should not be confused with consultation that is part of the ongoing services provided in your routine job duties but is a request to address a particular issue at a particular site, either external or internal.  Consultation may include (but is not limited to) developing or evaluating a program or service, developing a strategy for long-term planning, establishing outcomes measures, incorporating national guidelines into internal policies and procedures, assessing and addressing staff educational needs, assessing and addressing resource needs, and validating program/service delivery with current evidence.  Applicant must have had a minimum of 10 hours working with the site. 14. 1. 15. Entity for Which 16. Consultation Was Completed 18. 17. Date(s) of Consultation 19. No. of Hours Completed 20. During Consultation 21. 2. Objectives for consultation. Objectives must have been met by time of application. Please list no more than 3. A)

22. 3. Summarize the consultation results. (average word guideline–200) 23. 24. 4. Summarize how this professional development activity influenced your ability to “evaluate effectiveness of services delivered, either for caseload or programs, in order to validate service delivery and make changes as appropriate to maximize outcomes related to gerontology.” (average word guideline–400) 25. 26. 27. PROGRAM/SERVICE EVALUATION 28. Table of Contents 29. 30. Criterion 9–Outcomes 31. Evaluates effectiveness of services delivered, either for caseload or programs, in order to validate service delivery and make changes as appropriate to maximize outcomes related to gerontology.

32. 33. Guidelines  Refers to an activity implemented in a program, department, facility, or organization.  Should not include any form of standard client documentation (e.g., evaluation summary, discharge plan) or identification of client name(s) or facility information. 34. 35. 1. 36. Type of Program/Service Being 37. Evaluated 39. 38. Date(s) of Evaluation

40. 2. Describe the caseload or program being evaluated. The context should be adequately communicated so that relevance and merit to the criterion is easily determined. (average word guideline–300) 41.

42. 3. Identify methods or tools used for the program/service evaluation. (average word guideline–200) 43. 44. 45. 4. Summarize evaluation findings. (average word guideline–200) 46. 47.

48. 5. What actions were taken in response to the findings? (average word guideline–300) 49. 50.

51. 6. Summarize how this program evaluation demonstrates your ability to “evaluate effectiveness of services delivered, either for caseload or programs, in order to validate service delivery and make changes as appropriate to maximize outcomes related to gerontology.” (average word guideline–300) 52. 53.

54. 55. RESEARCH 56. Table of Contents 57. 58. Criterion 9–Outcomes 59. Evaluates effectiveness of services delivered, either for caseload or programs, in order to validate service delivery and make changes as appropriate to maximize outcomes related to gerontology.

64. ☐ Systematic review of the literature–Comprehensive search, review, and analysis of the existing literature to answer a focused question. 65. 1. Title of research conducted. 66. 67.

69. ☐ Publication

73. ☐ Dissertation/thesis 74. 75. Citation: 76.

80. 81. 82. 83. 84. 85. 86. 4. Purpose and rationale of the research. (average word guideline–250) 87. 88.

89. 5. Describe how this research demonstrates your ability to “evaluate effectiveness of services delivered, either for caseload or programs, in order to validate service delivery and make changes as appropriate to maximize outcomes related to gerontology.” (average word guideline–400) 90. 91. 92. HOLISTIC PRACTICE CASE STUDY 93. Table of Contents 94. 95. Criterion 10–Holistic Practice 96. Holistically addresses the client’s needs, including physical, social, and emotional well- being, that may impede occupational performance.

97. 1. Identify the primary reason for referral:

98. ☐ Physical

99. ☐ Social

100. ☐ Emotional 101. 2. Date(s) case study represents. 102. 3. Describe the client, client factors, and case contexts for the identified case. (average word guideline– 300) 103.

104. 4. Describe the other client needs (physical, social, emotional) you identified over the course of service delivery and how you addressed these needs. (average word guideline–100) 105. 106. 107. 108. 5. Articulate how this case demonstrates your ability to “holistically address the client’s needs, including physical, social, and emotional well-being, that may impede occupational performance.” (average word guideline–500) 6. 109. 110. ADVOCACY CASE STUDY Table of Contents

Criterion 12–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 gerontology practice area.

Guidelines  Efforts toward change that influence access to services or promote the health and occupational engagement of clients.  This should not be confused with routine job duties associated with expected occupational therapy service delivery. For example, submitting letters of necessity for equipment would not meet intent.

1. Date(s) case study represents.

2. Describe the client (person, organization, population) or program and the context as it applies to an identified need for change. (average word guideline–100)

3. Summarize your efforts to influence change. (average word guideline–200)

4. Describe the change outcomes or progress toward change as a result of your efforts. (average word guideline–200) 5. Articulate how this case demonstrates your ability to “advance access to services or influences policies or programs that promote the health and occupational engagement of clients (persons, organizations, populations) in the gerontology practice area.” (average word guideline–500) ADVOCACY EFFORTS Table of Contents

Guidelines  Active involvement in or facilitation of advocacy activities at the local, regional, state, or national level for the purpose of influencing decision-makers about policy, procedures, services, reimbursement, or occupational justice issues.  Merely serving as a participant does not constitute advocacy efforts.  Minimum of 10 hours over at least 2 months.

Type of advocacy activity: (check all that apply)

☐ Development and dissemination of advocacy materials (e.g., letters, brochures, Web sites, podcasts) ☐ Lobbying to/education for policy-makers ☐ Organizer of community event (e.g., fundraising, health fair) ☐ Subject expert in media interview (e.g., radio, television news, newspaper) ☐ Presentation to stakeholder ☐ Other

1. No. of Hours Description of Activity Target Audience Date(s) Involved

2. Applicant’s objectives for advocating for change. List no more than 3. A)

C) 3. Discuss the results, outcomes, or progress toward change affected by this advocacy effort that demonstrates how you “advance access to services or influences policies or programs that promote the health and occupational engagement of clients (persons, organizations, populations) in the gerontology practice area.” (average word guideline–350) VOLUNTEER LEADERSHIP Table of Contents

Guidelines  Service with a local, state, national, or international agency or organization that has relevance to the criterion.  Minimum of 25 hours for at least 1 year.

1. Name of organization

2. Dates of service

3. Approximate number of hours of service

4. Identification of the volunteer leadership role served (must be leadership in nature, e.g., officer, chair, committee member, board member)

5. Describe how this leadership activity helped you to “advance access to services or influences policies or programs that promote the health and occupational engagement of clients (persons, organizations, populations) in the gerontology practice area.” (average word guideline–400) NETWORKING CASE STUDY Table of Contents

Criterion 13–Accessing Networks & Resources Negotiates the service delivery system to establish networks and collaborate with team members, referral sources, or stakeholders to support clients’ occupational engagement.

Guidelines  The networking case study should reflect an understanding of the system in which you work and an ability to access resources outside of your routine work group and referral pathways.  The networking case study should not include any form of standard client documentation (e.g., evaluation summary, discharge plan).

1. Date(s) case study represents.

2. Identify the problem(s) that interfered with the client’s (person, organization, population) occupational engagement. (average word guideline–100)

3. Identify the key networks or resources you established or accessed to address the problem. (average word guideline–100) 4. Articulate how this case demonstrates your ability to “negotiate the service delivery system to establish networks and collaborate with team members, referral sources, or stakeholders to support clients’ occupational engagement.” (average word guideline–500)