OFFICIAL USE ONLY:
Reviewer’s Signature: _____________________
Not Approved: _____________________
Approved: _____________________
LOUISIANA OCCUPATIONAL THERAPY ASSOCIATION
OCCUPATIONAL THERAPY COURSE APPROVAL REQUEST
(Home-Study Courses Excluded)
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Course Title:
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Date(s) and hours of instructions NOT including lunch or breaks:
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Location(s):
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Sponsoring Organization:
Name, Address, Phone Number and Email for Contact Person:
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Course Instructor:
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Course Instructor background information:
(i.e. education, employment, publication and instruction experience, attach CV.)
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Specifically, how will monitoring of course participation and completion be handled?
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Course content/outline (may attach):
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Course objectives and goals (may attach):
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Indicate if this continuing education activity has been approved for credit by any other professional organizations or licensing boards:
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Attach a copy of all handouts or written course materials along with an outline of visual aids to be utilized.
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Enclose a NON REFUNDABLE $30.00 per course processing fee.
Make check payable to: Louisiana Occupational Therapy Association or LOTA.
Allow not less than 60 days for request to be processed.
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Enclose a self-addressed and stamped envelope so that a reply may be sent to you.
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Mail this form and payment to:
CONTINUING EDUCATION COURSE APPROVAL
LOUISIANA OCCUPATIONAL THERAPY ASSOCIATION
PO BOX 14806
BATON ROUGE, LA 70898
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If you have questions, please contact the LOTA Office at: 225-291-2806
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