Free 52567.FH11 - Indiana

INDIANA OCCUPATIONAL THERAPY COMMITTEE AFFIRMATION OF SUPERVISION
State Form 52567 (3-06)

INDIANA OCCUPATIONAL THERAPY COMMITTEE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected]

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Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given.

INSTRUCTIONS:

Applicants who are applying for a temporary permit to practice as an occupational therapist or occupational therapy assistant must have this supervision letter completed. This letter must be completed and have an original signature by the certified Indiana occupational therapist who will be providing direct supervision. Faxed copies are not acceptable. The supervising occupational therapist shall be reasonably available and responsible at all times for the direction and action of the person supervised when services are performed by the holder of a temporary permit. Unless the supervising occupational therapist is on the premises to provide constant supervision, the holder of a temporary permit shall meet once each working day to review all patients treatments.

APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Social Security number *

HOSPITAL / FACILITY INFORMATION
Name of hospital / facility Address (number and street or rural route, city, state and ZIP code)

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Telephone number

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TO BE COMPLETED BY SUPERVISOR I hereby swear or affirm, under the penalties of perjury, that the applicant whose name appears above will be under my direct supervision while practicing occupational therapy. According to IC 25-23.5-5-11 (b) and 844 IAC 10-5-13, I understand that I shall be available and under all circumstances shall be absolutely responsible for the direction and the actions of the person supervised when services are performed. I also understand that the patients care shall always be my responsibility.
Signature of supervisor Printed name of supervisor Certification number Date of expiration (month, day, year) Date signed (month, day, year) Telephone number

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Date supervision is to begin (month, day, year)