PROFESSIONAL MEMBERSHIPS If more than 4, combine multiples in 1 box. Organization Name Organization’s Focus/Mission Dates of Membership If more than 4, please list additional here. EMPLOYMENT--CURRENT Primary Employer Name Dates with Employer Current Position or Title Employer Address City State ZIP Type of Setting Academic Institution Setting Government--Federal Government--Local, State Home Health Agency Long-term Care Facility/SNF Hospital Setting Military Non-profit Agency Private Industry Private Practice Rehab Facility School System Other (please specify): ____________________ Clients Served Please identify the populations served at this setting on which this application is based.
EMPLOYMENT – CURRENT Secondary, if applicable Employer Name Dates With Employer Current Position or Employer Address City State ZIP Type of Setting Academic Institution Community-Based Setting Government--Federal Government--Local, State Home Health Agency Long-term Care Facility/SNF Hospital Setting Military Non-profit Agency Private Industry Private Practice Rehab Facility School System Other (please specify): Clients Served Please identify the populations served at this setting on which this application is based. EMPLOYMENT--PAST If there are employers in the past 5 years other than those listed above, please identify below. Previous Employer Name State Dates With Previous Employer
ETHICAL PRACTICE SCENARIO (Part 1 of 3)—Client Criterion 13—Ethical Practice: Identifies ethical implications associated with the delivery of environmental modification services and articulates a process for navigating through identified issues. Guidelines The applicant identifies ethical implications associated with the delivery of services and articulates a process for navigating through the identified issues. The applicant shall review the and align the dilemma with the ethical principle(s) that is/are challenged. Ethical Scenarios Scenario #1 During a home to implement an environmental intervention plan, an OT practitioner discovers that the client’s home is filled with clutter that impedes clear pathways, limits places to sit and covers all surface areas. She also notices cockroaches in the kitchen and rodent droppings in several rooms. The practitioner expresses her concern regarding safety with the client, but the client becomes tearful and asks the practitioner not to say or document anything because her daughter will have her moved to a nursing home. Scenario #2 The adult son of an elderly woman living alone with a diagnosis of early dementia contracts OT services to recommend adaptations to make her safer at home. After the evaluation, the OT practitioner presents the recommendations to the woman and her son. The son is receptive; however, his mother adamantly refuses all suggestions, insisting there is nothing wrong with her, and that her children should stop interfering. Scenario #3 An OT practitioner is working on wayfinding and topographical orientation in a long term care facility with a client diagnosed with dementia, who has difficulty locating her room and the bathroom. The client is not able to discriminate written words, including her name, and has difficulty with the picture symbols used to identify her room and the bathroom. The practitioner determines that the client is able to discriminate and follow a photograph of the bathroom placed on the bathroom door, as well as a photo of her own face placed next to her name outside her bedroom door to assist in locating her proper room. The facility tells the practitioner that the client’s picture next to her name on the door causes a privacy issue. To which scenario are you responding? _________ From the , which ethical principle(s) has/have been challenged in this scenario? Select the top ethical principle(s) that apply, up to a maximum of 3. 1. Beneficence 2. Non-maleficence 3. Autonomy 4. Justice 5. Veracity 6. Fidelity
Professional Development Goal 1 To which criterion does this goal apply? (Check 1) Knowledge: Diagnostic Considerations Knowledge: Evaluation Knowledge: Intervention Knowledge: Regulation and Payers Evaluation: Performance Skills Evaluation: Critical Reasoning Intervention: Performance Skills Intervention: Critical Reasoning Psychosocial Critical Reasoning Ethical Practice Establishes Networks Advocating for Change Applicant’s Goal 1: Professional Development Goal 2 To which criterion does this goal apply? (Check 1) Knowledge: Diagnostic Considerations Knowledge: Evaluation Knowledge: Intervention Knowledge: Regulation and Payers Evaluation: Performance Skills Evaluation: Critical Reasoning Intervention: Performance Skills Intervention: Critical Reasoning Psychosocial Critical Reasoning Ethical Practice Establishes Networks Advocating for Change Applicant’s Goal 2: Professional Development Goal 3 To which criterion does this goal apply? (Check 1) Knowledge: Diagnostic Considerations Knowledge: Evaluation Knowledge: Intervention Knowledge: Regulation and Payers Evaluation: Performance Skills Evaluation: Critical Reasoning Intervention: Performance Skills Intervention: Critical Reasoning Psychosocial Critical Reasoning Ethical Practice Establishes Networks Advocating for Change Applicant’s Goal 3: