Volunteer Hours Verification Form
KENT STATE UNIVERSITY AT EAST LIVERPOOL
OCCUPATIONAL THERAPY ASSISTANT TECHNOLOGY
VOLUNTEER HOURS VERIFICATION FORM
This form is to be completed by a licensed Occupational Therapist, or Occupational Therapy Assistant.
Forms completed by anyone other than an OT or OTA will not be accepted. Volunteer experiences cannot be evaluated by a relative or personal friend. Please present this form to your supervising therapist with a stamped envelope addressed to the OTA Program. The total number of required hours is 40, divided between 2 different sites, 20 hours each. Please complete the next section completely.
A. Applicant’s Name
B. Facility Name & Address
C. Facility Phone Number
D. Number of Hours Completed
E. Please sign the following waiver prior to giving this form to the supervising therapist.
I waive the right to view this completed form in order to afford an unbiased evaluation by the supervising therapist.
II. OCCUPATIONAL THERAPY PRACTITIONER:
Please rate the applicant on the following behavioral characteristics:
|Characteristics||Above Average||Average||Below Average|
|a. Professional behaviors (dress, punctuality, etc.)|
|b. Communication & interaction skills|
|c. Ask relevant questions|
|d. Ability to relate to clients|
|e. Organization & preparation for observation (scheduling, understanding facility population)|
Please understand that the Admissions Committee relies heavily on your observations and input. We appreciate any insights you have to offer. Indicate the level of your overall endorsement of the candidate.
_______ Highly recommended
_______ Recommend with reservation
_______ Not recommended
Printed Name of Evaluator: ____________________________________________________________________
Signature ____________________________________________________ State & License No. ________________
PLEASE NOTE: VOLUNTEER HOURS WILL NOT BE ACCEPTED IF MORE THAN TWO YEARS OLD.
PLEASE MAIL TO:
Harriett S. Bynum, MS, OTR/L
Occupational Therapy Assistant Program
Kent State University
East Liverpool Campus
400 East Fourth St.
East Liverpool, OH 43920