Download Temporary OTA License for New Graduate (Word)

HEALTH OCCUPATIONS P ROGRAM
Occupational Therapy Licensing
P.O. Box 64882, St. Paul, Minnesota 55164-0882
Telephone: (651) 201-3724
Fax: (651) 201-3839
Email: [email protected]
Occupational Therapy Assistant (OTA) Temporary License: New Graduate
APPLICATION AND INST RUCTION CHECKLIST
IMPORTANT THINGS TO KNOW ABOUT THE APPLICATION PROCESS:
▪
▪
▪
▪
▪
After MDH received all necessary documents, it will take five (5) to ten (10) business days to review your OTA
temporary license application for approval. To ensure that your application is processed in a timely matter,
complete all the steps in this checklist.
MDH will not approve your application until we receive: 1) a completed and signed application; 2) all requested
documentation; and 3) license fee payment.
Any applications mailed 30 days after the date of signature on the application will be returned to you to confirm that
information is still current.
If a question on the application doesn’t apply to you, respond “N/A.”
When you are approved for an OTA temporary license, you will receive a letter in the mail from MDH confirming
your licensure.
APPLICATION CHECKLIST
☐
Print this document and check off the instructions as you complete them.
☐
Complete Part I of the application.
☐
Then have your occupational therapist supervisor complete Part II.
▪ You may only report one employer, place of employment and supervisor in your initial temporary OTA
license application.
▪ If you have more than one supervisor and/or place of employment to report, you can report this additional
information after you have receive your approval letter from MDH.
☐
Complete, sign, and date the records Waiver & Release form.
☐
Enclose a check or money order for $50 and make payable to “Treasurer: State of Minnesota.”
▪ All fee payments received are deposited immediately and are non-refundable.
▪ No additional fee is required for OTA Temporary License application forms submitted to show additional
employers, supervisors and/or places of employment.
☐
Make a copy of your application and all supporting documents for your records.
☐
Mail completed original application, supporting documents, and fee payment to MDH.
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OTA TEMPORARY LICENSE APPLICATION CHECKLIST
APPLICATION CHECKLIST (continued):
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Contact the school you completed your occupational therapy degree at and request an official transcript to be
sent directly to MDH. If you have recently graduated and a transcript is not yet available to verify your degree,
we will accept a letter or certificate of completion sent directly to MDH from the school, but an official transcript
must be requested when it becomes available. Send all letters and transcripts directly to MDH at:
Minnesota Department of Health
Health Occupation Program
Attn: OTA Licensing
P.O. Box 64882
St. Paul, MN 55164-0882
Courier–Overnight Delivery Address:
Minnesota Department of Health
Attn: OTA Licensing
85 East Seventh Place, Suite 220
Saint Paul MN 55101
NOTE: We will not accept a transcript or letter unless it is in an unopened, sealed envelope from your school.
WHAT HAPPENS NEXT?
You may begin to practice as soon as your name appears on our Health Occupations Program Credential
Lookup website. This website is updated daily. Your name will appear on our website the day after your
license has been issued.
ONCE YOU RECEIVE YOUR OTA TEMPORARY LICENSE APPROVAL FROM MDH:
1. Report other employers, supervisors, and/or places of employment to MDH by completing
additional OTA Temporary License: New Graduate application(s).
▪ You must report any additional supervisors, employers, and/or additional work locations to
MDH within 30 days.
▪ If you are just adding an additional supervisor to a current work location, you and the
additional supervisor will need to complete page 2 of the application.
▪ If you have more than one employer or place of employment, you and your occupational
therapy supervisor must complete page 2 of the application for each work location.
▪ You can scan and email additional applications to [email protected] or fax to them to
(651) 201-3839.
▪ No fee is required for additional applications that are submitted showing additional
employers, supervisors, and/or places of employment.
▪ Once approved, your temporary license is good for six (6) months.
▪ You may only renew your temporary license once.
▪ If you fail the NBCOT exam, you can continue to work as long as your license is current.
2. Send your supervisor(s) a copy of your OTA temporary license approval letter. MDH doesn’t notify
supervisors or employers when license applications are approved.
QUESTIONS
If you have any questions about the application process or submitting the required documents, please
email [email protected] or call (651) 201-3724.
If you require an alternate format (i.e., large print), please call (651) 201-3731.
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HEALTH OCCUPATIONS P ROGRAM
Occupational Therapy Licensing
P.O. Box 64882, St. Paul, Minnesota 55164-0882
Telephone: (651) 201-3724
Fax: (651) 201-3839
Email: [email protected]
Application for Occupational Therapy Assistant (OTA) Temporary License: New Graduate
MINNESOTA GOVERNMENT DATA PRACTICE ACT NOTICE. This notice is given pursuant to Minnesota Statutes, section 13.04, subd. 2, and section 13.41,
subd. 2. The Commissioner of the Minnesota Department of Health (Commissioner) will use information provided in this application to determine if you
meet Minnesota Statutes, sections 148.6401 to 148.6450 requirements for licensing. You are not legally required to supply the requested information.
However, FAILURE TO PROVIDE INFORMATION OR THE SUBMISSION OF FALSE OR MISLEADING INFORMATION MAY DELAY THE PROCESSING OF YOUR
APPLICATION OR MAY BE GROUNDS FOR DENYING YOUR APPLICATION. All data, except your name and address, submitted by you or on your behalf are
considered private until you are licensed. Once you become licensed, all application data except your Social Security Number and non-designated address
become public and will be released to anyone upon request. Information in your application may, in some circumstances, be disclosed to other Minnesota
Department of Health staff, the Occupational Therapy Advisory Council, The Minnesota Attorney General’s Office, and any person to whom the
Commissioner must refer your application for verification or to otherwise determine your qualifications. Application data may also be disclosed to an
appropriate person or agency to prevent a clear and present danger. If you contest the Commissioner’s decision regarding your license, resulting in a
contested case hearing or litigation, your application data becomes accessible to the Minnesota Office of Administrative Hearings, appropriate courts, and
those associated with such proceedings, and may become accessible to the public.
PART I
To be completed by applicant only. Please print and sign clearly in blue ink.
OCCUPATIONAL THERAPY ASSISTANT LICENSE STATUS & HISTORY
Do you currently have a MN OTA license?
☐ Yes
☐ No
MN OTA License #
Is this a renewal of your OTA temporary license?
☐ Yes
☐ No
MN OTA License #
Have you ever held an OTA license in Minnesota?
☐ Yes
☐ No
MN OTA License #
ADDITIONAL EMPLOYMENT INFORMATION
Do you have more than one OTA supervisor?
☐ Yes
☐ No
If yes, how many?
Do you have more than one OTA employer?
☐ Yes
☐ No
If yes, how many?
Do you have more than one OTA work location?
☐ Yes
☐ No
If yes, how many?
Are you submitting this application because you have been approved for your
OTA temporary license and need to report additional employment information?
☐ Yes
☐ No
If yes, fill out an application for each additional
supervisor, employer and/or work location.
EDUCATION
Name of School
City and State
Date Transcript Requested (MM/DD/YYYY)
Last Name
First Name
Graduation Date (MM/DD/YYYY)
PERSONAL INFORMATION
Middle Name
Home Mailing Address – Street (P.O. Box address will not be accepted)
City
Home Telephone Number
Cell Phone Number
State
Zip Code
Email Address
Date of Birth (MM/DD/YYYY)
Social Security Number (S.S. # is required by MN Statute, section 270.72, subd. 4)
Where would you prefer to receive mail from MDH regarding your occupational therapy assistant license?
The address you select will be public information.
Have you ever used another legal name under which records may be filed concerning your application, including your education training
or experience? If yes, please list name(s) used (First Name, Middle Name, Last Name):
☐ Male
☐ Female
☐ Home
☐ Employer
☐ Yes ☐ No
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OTA TEMPORARY LICENSE APPLICATION
Applicant Name:
PART I (continued)
INSTRUCTIONS. Licensed occupational therapy assistants are required to report all supervisors, employers and places of employment (work
locations) to MDH. If this is the first time you have applied for a temporary license, you only need to initially apply using one supervisor, employer,
and place of employment. After you have received your temporary OTA license, you will report the rest of your supervisors and/or places of
employment, if any.
APPLICANT’S PLACE OF EMPLOYMENT (WORK LOCATION)
Name of Place of Employment (i.e., work location)
Work Address – Street
City
Work Telephone Number
Work Fax Number
State
Zip Code
Work Email Address
APPLICANT AFFIRMATION OF UNRESTRICTED LICENSE:
I hereby make application for a temporary license. I have completed the educational requirements for licensure as described in Minnesota
Statutes, sections 148.6401 to 148.6450, including fieldwork placement. I understand that as a temporary licensee, I must practice under the
supervision of a Minnesota licensed occupational therapy assistant. I understand that a temporary license expires six months from the date of
issuance and that to continue practicing and using a protected title after the expiration of a temporary license, I must apply for and obtain either 1)
a renewal of my temporary license, or 2) full licensed status as an occupational therapist.
By signing below, I certify that:
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I have read and will comply with the requirements of Minnesota Statutes, sections 148.6401 to 148.6450.
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I am not the subject of a pending investigation or disciplinary action for occupational therapy practice in this or any other state.
▪
I have not been subject of a disciplinary action for occupational therapy practice in this or any other state.
I understand that approval of temporary license and status as a temporary licensee creates no rights to or expectation of approval of the Minnesota
Department of Health for a license as an Occupational Therapy Assistant.
Applicant Signature
Date
PART II
To be completed by supervisor. Please print and sign clearly in blue ink.
Last Name
First Name
Middle Name
License Number
Name of Place of Employment (i.e., work location)
Employer
Work Address – Street
City
Work Telephone Number
Home Telephone Number
Work Fax Number
Work Email Address
Date Supervisor Started Employment (MM/DD/YYYY)
Date Supervisor Notified MDH of This Employment (MM/DD/YYYY)
State
Zip Code
I certify that I am a licensed occupational therapist in the state of Minnesota and the supervisor of the above-named applicant who has applied for
temporary license pending receipt of a qualifying score on the examination required for licensing by Minnesota Statutes, sections 148.6401 to
148.6450.
I have read Minnesota Statutes, section 148.6418 and will provide supervision consistent with subd. 4. I understand that a temporary license expires
six months from the date of issuance for occupational therapy assistant or on the date the commissioner grants or denies licensure, whichever
occurs first. Furthermore, I understand that I am the responsible supervisor for the above applicant until the Minnesota Department of Health
receives my written and signed statement that I wish to cease supervision or until expiration of the temporary license.
Supervisor Signature
Date
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OTA TEMPORARY LICENSE APPLICATION
Applicant Name:
WAIVER & RELEASE
To be completed by applicant only. Please print and sign clearly in blue ink.
Under the Minnesota Government Data Practices Act, Minnesota Statutes, Chapter 13, all information received as part of an active investigation is
confidential data. If my application for a temporary license as an occupational therapy assistant is approved, I hereby authorize the Minnesota
Department of Health to notify my supervisor in the event the Department receives a complaint against me concerning an act or omission related to
the provision of occupational therapy services.
By signing below, I waive any privilege afforded to me by law relating to the disclosure of complaint information and allegations. I further release
the Department, its agents or employees from liability for releasing complaint information and allegations to my supervisor. This waiver will remain
in effect until the approved temporary license expires, is revoked or suspended, or until the temporary licensee or approved supervisor listed on this
application notifies the Department, in writing, that supervision has been withdrawn.
Applicant Signature
First Name, Middle Name and Last Name (Printed)
Home Address
City, State and Zip Code
I have read and understand the instructions for this application process.
Applicant Signature
Date
If you require an alternate format (i.e., large print), please call (651) 201-3731
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