ATP Application Materials Checklist

Candidates shall NOT be authorized to sit for the exam without the following materials: ___ Completed application form: _ 1st page: Contact and demographic info, credit card info (if paying the fee by credit card), indication of special accommodations needed. _ 2nd page: Education and experience information and attestation signature. _ 3rd page: Work Verification Form which must indicate: a. A complete description of your AT direct consumer service related work responsibilities and duties; b. The time spent in AT direct consumer service in a typical work week; and c. Supervisors signature and contact information. _ 4th page: Good Moral Character Affirmation Form _ 5th page: For supervisors/owners only to verify work experience (in addition to filling out page 3 (self-reported) Copy(ies) of your educational degree(s). If you do not have a copy of your degree, you may submit a copy of your college transcript as long as it specifies program completion and degree earned. A license or registration may not be substituted. If you are attempting to qualify for certification with a high school diploma, you must submit your diploma or GED, and documentation demonstrating you have completed at least 30 contact hours of training in assistive technology in the past. Examples of AT training include continuing education courses, seminars, manufacturers training sessions. Documentation must specify the number of contact hours earned and be signed by the training administrator. ___ Application Fee a. $500 for 1st time or re-test more than 1 year since last exam attempt; or b. $250 for retest within 1 calendar year since last exam. c. A $50 processing fee is kept for cancellations

___

Mail all pages of the completed application with supporting documentation to: RESNA 1700 North Moore Street Suite 1540 Arlington, VA 22209-1903 Phone: 703-524-6686, Fax: 703-524-6630, Email: credentials@resna.org A confirmation e-mail will be sent to the e-mail address provided on page 1 with instructions on setting up the exam.

COMPUTER-BASED TESTING
(Exam is given on an as-needed basis. Please see the Prometric test center page for a list of cities with testing centers. http://www.prometric.com/RESNA)

Application Form
1. LAST NAME: (Please print or type clearly)

FIRST NAME & MIDDLE INITIAL

2. PREFERRED MAILING ADDRESS: (this will be listed on the RESNA website directory)

Application and Test Fee: $500

COMPANY/ORGANIZATION

Check Money Order Master Card Visa

NO & STREET

PO BOX OR APT. NO. Note: We do not accept American Express or Discover Cards CITY, STATE/PROV, ZIP, POSTAL CODE

Credit Card Number:

3. OFFICE PHONE: (Include area code)

Expiry Date:

4. FAX: (Include area code)

Name on Card:

5. EMAIL ADDRESS (please print clearly)

3-Digit Security Code on back of card: Billing Address:

6. SELF DESRIPTION (Voluntary)

__________________________ __________________________ __________________________ __________________________

Do you require special accommodations? (If so, please contact office & provide written medical documentation to support your request)

a. American Indian b. Asian American c. African American d. Caucasian

e. Chicano/Mexican American f. Puerto Rican/Puerto Rican American g. Spanish American h. Other ______________________________

7. GENDER
Male Female

8. MY PRIMARY PROFESSIONAL SETTING IS:

a. Educational Facility b. Independent Living Center c. Medical Rehabilitation Facility d. Manufacturing Facility e. DME Supplier f. Private Practice/Community Based Practice g. Vocational Rehabilitation Facility h. Government Agency i. Other _______________________________

If yes:

Yes

No

9. MY PRIMARY FIELD IS:

a. Counselor b. Educator c. Engineer d. Manufacturer e. Physician f. Nurse

Seating accommodation Individual proctor or reader needed Extended time needed Other: contact office immediately to discuss appropriate accommodation

g. Supplier h. Technician i. OT k. PT m. SLP

j. OTA l. PTA n. SLPA

o. Other ______________________________

10. EDUCATIONAL LEVEL (Check only one):

a. Bachelor Degree (or higher) in a Rehabilitation Science b. Associate degree in a Rehabilitation Science c. Bachelor Degree (or higher) in a non-Rehabilitation Science d. Associate degree in a non-Rehabilitation Science e. High School Diploma or GED

11. TOTAL NUMBER OF YEARS EXPERIENCE IN ASSISTIVE TECHNOLOGY:

Verification of Work Experience in Assistive Technology

If there are multiple employers identified during the period used for eligibility photocopy, and submit one form for each employer SECTION I: To be completed by applicant.
APPLICANT'S NAME: ORGANIZATION: ADDRESS: SUPERVISOR'S NAME: TELEPHONE: DATES OF EXPERIENCE /EMPLOYMENT:

SECTION II: To be filled out and signed by Applicant:

Direct consumer related services in Assistive Technology is defined as those services that are provided in-person to consumers and others related to or working with consumers. It may include, but is not limited to, the following*: 1. Evaluations, assessments, and other direct-to-consumer/student services (needs assessment, physical/functional/sensory assessments, educational assessments, site assessments, simulations and product trials) 2. Fitting, adjustment and readjustment services (fine tuning of equipment to meet the consumer/students needs and reflect changes in the consumer/students status) 3. Implementation and training for consumers/caregivers or students/support personnel (training in use of AT or strategies to maximize function and interface with the environment(s) of use, instruction in use and/or maintenance) 4. Product development that involves direct consumer participation

40 hours / week x ___ weeks / year 32 hours / week x ___ weeks / year 30 hours / week x ___ weeks / year 24 hours / week x ___ weeks / year 20 hours / week x ___ weeks / year 16 hours / week x ___ weeks / year 10 hours / week x ___ weeks / year 8 hours / week x ___ weeks / year 4 hours / week x ___ weeks / year

1.0 FTE

_____ hours / year _____ hours / year

.75 FTE

_____ hours / year _____ hours / year

.50 FTE

_____ hours / year _____ hours / year _____ hours / year

Any combination of services in the broad spectrum of Assistive Technology service delivery that total the required number of work experience hours based upon your educational background.

.25 FTE

_____ hours / year

_____ hours / year

Describe your weekly job responsibilities in direct AT service work or attach your job description and validation of your time performing the job responsibilities.

Average hrs/ week

# of weeks worked

* The following services related to assistive technology would not be applicable for inclusion in the total work experience hours. This list is not all inclusive. The applicant
may appeal an adverse decision on work verification to the Professional Standards Board. 1. Customer service, scheduling, information gathering and/or paperwork processing of assistive technology orders 2. Billing, collections and/or claims processing of assistive technology products/services 3. Professional development, didactic teaching or instructing providers/teachers on topics of assistive technology, which does not include consumer/student contact 4. Research and/or development, which does not include consumer/student contact 5. Telecommunication relay services

Good Moral Character Affirmation Questions

Please answer the following questions in order to address any issues that may be harmful to the public or inappropriate to the profession. A "yes" answer will not necessarily result in a denial of certification. However, please fully disclose any relevant information so that the RESNA Professional Standards Board can make an informed evaluation and decision.

1.

Have you ever been convicted of, pled guilty or no contest to, been acquitted by reason of mental disease or defect, entered into a diversion in lieu of prosecution, or had adjudication withheld on a felony charge in any legal jurisdiction?

Yes No

2.

Have you ever been convicted of, pled guilty or no contest to, been acquitted by reason of mental disease or defect, entered into a diversion in lieu of prosecution, or had adjudication withheld on a misdemeanor involving theft, fraud, bribery, corruption, perjury, embezzlement, solicitation, dishonesty, physical harm or threat of physical harm to the person or property of another or substance abuse in any legal jurisdiction?

Yes No

3.

Have you ever been subject to an adverse civil or administrative judgment for theft, fraud, corruption, embezzlement, solicitation, dishonesty, substance abuse, or other acts of moral turpitude (any offense that calls into questions the integrity or judgment of your actions)?

Yes No

4.

Are you currently or ever been subject to disciplinary action (i.e. sanctioned, reprimanded, suspended, or restricted) by any professional body, association, licensing authority, board or certifying association of which you were or are a member?

Yes

No

5.

Have you ever been discharged from employment for theft, fraud, corruption, embezzlement, solicitation, dishonesty, substance abuse, or other acts of moral turpitude (any offense that calls into questions the integrity or judgment of your actions)?

Yes No

Note: No applicant will be denied solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense will be considered. I, the undersigned, certify the above and accompanying eligibility information is correct. I also acknowledge and accept the regulations of the RESNA Professional Standards Board and recognize this Board as the sole and only judge of my qualifications to receive and retain a certification issued on behalf of the Board and to have my name published in any list or directory in which certified, or de-certified, individuals are listed. I pledge to follow the RESNA Code of Ethics and RESNA Standards of Practice in my work with assistive technology.

I declare and affirm that the statements made in this certification application are complete and correct, understand that I may be subject to a random audit and a background check and that any false or misleading information may be cause for denial or disciplinary action. (tie this wording in with the current wording below page 3 To the best of my knowledge and belief I am in compliance with the RESNA Code of Ethics and Standards of Practice.

Signature

Date

Verification of Work Experience in Assistive Technology Service Delivery

If multiple employers during the period used for eligibility, photocopy and submit one form for each employer. SECTION I: To be completed by applicant.

APPLICANT'S NAME: ORGANIZATION: ADDRESS:

SUPERVISOR'S NAME: TELEPHONE: DATES OF EXPERIENCE /EMPLOYMENT:

SECTION II: To be filled out and signed by Supervisor or Employer:

Please answer the following questions to verify the applicant's work experience and return to the applicant for submission with the completed application. NOTE: If you are an owner or supervisor and do not have other management to verify your experience, please fill out the description below and attach three references using the next page as needed to validate your eligibility.

PLEASE WRITE A DESCRIPTION OF THE APPLICANTS JOB RESPONSIBILITIES RELATED TO DIRECT ASSISTIVE TECHNOLOGY SERVICES TO THE CONSUMER:

TOTAL NUMBER OF HOURS IN A TYPICAL WEEK DEDICATED TO THE FOLLOWING RESPONSIBILITIES:

SUPERVISOR SIGNATURE

TITLE

DATES OF EMPLOYMENT: My current area(s) assistive technology practice is/are (check all that apply):

TODAYS DATE:

Augmentative/Alternate Communication Technology for Cognitive Disabilities Computer Applications Dysphagia/Eating, Swallowing or Saliva Control Electrical Stimulation Seating or Wheeled Mobility Other:

Job / Workplace Accommodations Personal Transportation Technology for Sensory Loss Special Education Telerehabilitation Universal Design / Accessibility

Verification of Work Experience in Assistive Technology Service Delivery

(For owners/supervisors only)
Please make THREE copies of this form to provide to references if you do not have other management staff at your work place able to verify your work experience over the time needed to meet eligibility requirements. SECTION I: To be completed by applicant.

APPLICANT'S NAME: ORGANIZATION: ADDRESS:

REFERENCE NAME: TELEPHONE: DATES OF EXPERIENCE /EMPLOYMENT:

SECTION II: I attest that I have worked with the applicant,____________________________, and have known them in a (candidate name) professional capacity, working in AT direct consumer related services for the period from _______________ to (beginning date) ________________. They have worked with me to provide the following services:

SIGNATURE & TITLE OF REFERENCE:

TODAYS DATE:

ATP Eligibility Matrix

RESNAs Professional Standards Board (PSB) regularly reviews the ATP certification program in order to maintain the programs high standards. As a result, the PSB has added eligibility information for those candidates with a Masters Degree or higher in Special Education or Rehabilitation Science, and a Bachelors Degree in Special Education. This means that candidates with these degrees have corresponding work experience requirements in line with their educational training. Please note that candidates approved for the exam prior to April 1st, 2012, do not have to reapply.

Degree Masters Degree or higher in Special Education Masters Degree or higher in a Rehab Science Bachelor Degree in Special Education Bachelor Degree in a Rehab Science Bachelor Degree or higher in a Non-Rehab Science Associate Degree in a Rehab Science Associate Degree or higher in a Non-Rehab Science HS Diploma or GED

Training/Education

Work Experience 1000 hours in 6 years 1000 hours in 6 years 1500 hours in 6 years 1500 hours in 6 years

10 hours

3000 hours in 6 years 2000 hours in 6 years

20 hours 30 hours

4000 hours in 6 years 6000 hours in 10 years