OCCUPATIONAL THERAPY ASSISTANT PROGRAM

Health Sciences Division OCCUPATIONAL THERAPY ASSISTANT PROGRAM Application Packet 2014 University System of Georgia An Affirmative Action/Equal Opportunity Institution Revised April 11, 2014

Health Sciences Division Dear Prospective Student: Thank you for your interest in the Occupational Therapy Assistant Program at Darton State College. Please note the OTA program has a selective admissions process, therefore due to the competitive nature of the selection process, careful preparation for application is highly recommended. The OTA program admits one class of 20 students per year that begins each fall semester (mid-august). The deadline to apply is June 1 st of the year you wish to enter the professional phase. The professional phase is completed over 4 semesters (16 months) with the student graduating the following fall semester (Fall, Spring, Summer, Fall). The deadline for applying (June 1) occurs during the SUMMER semester prior to the FALL semester start date. If a student is enrolled in courses that will complete all requirements during the Summer Semester of the June 1 deadline, the student may submit the application with those required courses still in progress. Graduates of the program will be eligible to sit for the National Board for Certification in Occupational Therapy (NBCOT) examination. After successful completion of this examination, the individual will be a Certified Occupational Therapy Assistant (COTA). Most states require licensure in order to practice; however, state licenses are usually based on the results of the NBCOT Certification Examination. *If you have a felony or have been convicted of legal and/or moral violations, NBCOT and the state licensure board have the right to refuse to grant you certification and/or licensure. ADMISSION CRITERIA To be considered for admission to the Occupational Therapy Assistant program, the applicant must: 1. Be admitted to Darton State College. If you are not already a Darton State College student, the first step is to apply to Darton State College. You may apply on-line at www.darton.edu/admin/admissions/ A $20 application fee is required at the time you apply to Darton State College. DO NOT send the college application or required $20 fee to the OTA Program. The two application processes are separate and no additional fee is required when submitting the OTA Program application. For transfer students: Official transcripts must be sent to the Darton State College Registrar s Office and must be received by the June 1 deadline. Please note that admission to the College does not ensure admission to the OTA program. 2. Complete the following requirements before applying to the OTA program. a. Must have a minimum cumulative grade point average of 2.5 or higher, or a 2.5 GPA overall or the last 40 credit hours completed. b. Must complete a minimum of 40 observational hours of work/volunteer experience in two or more occupational therapy settings. The hours must be documented and verified/signed by an occupational therapist or occupational therapy assistant.

You may submit any documentation form from the facility or utilize the Observational Hours Form located within the application packet. c. At least two recommendation forms must be completed by an OT or OTA. The required Recommendation Form is located within the application packet and may be photocopied for additional recommendations. d. Must have immunizations completed with current PPD within 3 months of June 1 deadline. The required Certificate of Immunization Form is located within the application packet and may be photocopied. e. Prerequisite coursework is required. It is highly recommended that ALL prerequisite coursework be completed prior to admission; however, an applicant may be accepted with prerequisite courses still in progress during the summer semester. All prerequisite coursework must be completed with a grade of C or higher. Course Number Prerequisite Coursework Credit Hours ENGL 1101 English Composition I 3 MATH 1111 College Algebra or higher math 3 CISM 2201 Fundamentals of Computer Applications 3 PSYC 1101 General Psychology 3 PSYC 2103 Human Growth and Development 3 POLS 1101 American Government 3 BIOL 1100K Human Anatomy & Physiology for the Health Care Professional -OR- Human Anatomy & Physiology I & II -OR- BIOL2111K & BIOL 2112K -OR- 4 & 4 Please note: BIOL 1100K is only offered at Darton State College and may be taken in lieu of Anatomy and Physiology I & II; however, BIOL 1100K will not transfer to another institution. Therefore, if you plan to continue your education after Darton State College, we recommend completing the series of Anatomy & Physiology I &II. Humanities course: Please choose only course from the list below: ART 1100 Art Appreciation 3 FIAR 2250 Humanities through the Arts 3 ENGL 2111 World Lit I 3 ENGL 2112 World Lit II 3 ENGL 2121 British Lit I 3 ENGL 2122 British Lit II 3 ENGL 2131 American Lit I 3 ENGL 2132 American Lit II 3 MUSC 1100 Music Appreciation 3 THEA 1100 Theater Appreciation 3 4

3. Submit the OTA application by the June 1 deadline. The student must complete an Occupational Therapy Assistant (OTA) Admission Application. It is the responsibility of the applicant to ensure all application material has been completed as directed and submitted by the deadline. Must include verification of a minimum of 40 observational hours. Must include at least two Recommendation Forms completed by an OT or OTA. Must include a hand written essay explaining why you have chosen OTA as a career. (There is no required length for the essay.) Must include a completed Prerequisite G.P.A. Form. The form is located within the application packet. SELECTION PROCESS The OTA Selection Committee reviews and scores each application based on the following criteria: grade point averages (Cumulative G.P.A. {or last 40 credit hours} and G.P.A. for all prerequisite coursework), the number of hours observed in two or more occupational therapy settings, the hand written essay, and appropriate recommendations received. OTA PROGRAM After acceptance into the program, the student will complete the following coursework as noted below. Fall Semester (12 credit hours) OTAS 1100 Introduction to Occupational Therapy 3 ALHE 1104 Introduction to Disease Conditions 2 OTAS 1105 Patient Care Skills for the OTA 2 OTAS 1111 Functional Anatomy & Kinesiology 4 ALHE 1120 Medical Terminology 1 Spring Semester (12 credit hours) OTAS 1121 Therapeutic Media 2 OTAS 1131 Physical Function in Occupation I 4 OTAS 1140 Psychosocial Function in Occupation 3 OTAS 1145 Developmental Function in Occupation 3 Summer Semester (11 credit hours) OTAS 1132 Physical Function in Occupation II 4 OTAS 2200 Assistive Techniques and Technologies 3 OTAS 2260 Treatment Methods & Management for the OTA 4 Fall Semester (12 credit hours) OTAS 2412 Occupational Therapy Seminar 2 OTAS 2410 Level II Fieldwork 5 OTAS 2420 Level II Fieldwork 5 Fieldwork must be passed to graduate. In the event of unsatisfactory performance, a practicum may be repeated one time within 18 months of completion of didactic course work.

ABOUT THE PROGRAM Mission: The Occupational Therapy Assistant Program at Darton State College strives to provide students with the knowledge and competencies needed to: Pass the National Board for Certification in Occupational Therapy (NBCOT) examination Practice as a generalist in both current practice settings and emerging practice settings as defined by the American Occupational Therapy Association (AOTA) Adhere to the upmost levels of professionalism and ethical behaviors Be actively involved in state and national occupational therapy associations and to become life-long learners Degree: Upon successful completion of the program, students will earn an Associate of Science degree and will be academically eligible for licensure by examination. Accreditation: The Occupational Therapy Assistant program is accredited by the Accreditation Council for Occupational Therapy Education (ACOTE) of the American Occupational Therapy Association (AOTA), located at 4720 Montgomery Lane, Suite 200, Bethesda, MD 20814-3449. AOTA s telephone number is (301) 652- AOTA. ACOTE s web address is www.acoteonline.org. LEGAL LIMITATIONS Individuals who have been convicted of a felony may not be eligible for licensure. If convicted of a felony, it is recommended that you contact the Occupational Therapy Board in the state where you plan to seek licensure to verify your eligibility for licensure. All students will be required to complete a national criminal background check prior to placement in clinical externships. Some clinical facilities may also require a drug screen prior to placement (students may be responsible for payment). The clinical affiliate determines whether a student can participate in the clinical rotation based upon the results of the background check and drug screen. GEORGIA STATE BOARD OF OCCUPATIONAL THERAPY www.sos.ga.gov/plb/ot/ FINANCIAL AID Financial Aid is available for students who qualify. Darton State College Financial Aid Department Building K, Room 111 Phone (229) 317-6746 Fax (229) 317-6607 www.darton.edu/admin/finaid/ NON-DISCRIMINATION POLICY Darton State College, in compliance with Federal law, does not discriminate based on race, color, national origin, handicap, sex, religion, or age in any of its policies, practices, or procedures. This includes but is not limited to admissions, employment, financial aid, and educational services. The faculty of the Occupational Therapy Assistant program acknowledges Section 504 of the Rehabilitation Act of 1973 and PL 103-336, The Americans with Disabilities Act and will consider for admission, progression, and graduation candidates who demonstrate the ability to perform the essential abilities. These standards are admission guidelines and are subject to continuing revision and improvement.

FREQUENTLY ASKED QUESTIONS How do I go about getting the required observational hours? All applicants must complete a minimum of 40 hours of clinical observation by JUNE 1 st in any type of occupational therapy setting such as a hospital, skilled nursing facility, out-patient facility, etc. This requirement is designed to give the applicant a better understanding of the role of the occupational therapy assistant. Applicants who currently work in an occupational therapy setting may complete all hours at that facility, however, they must be directly under the OT or OTA observing patient care and not part of the secretarial staff. This is not a service performed by the college; the applicant must independently seek out a occupational therapy setting and speak with the appropriate staff/personnel regarding observational hours. There are many occupational therapy providers to choose from, check out your local yellow pages. Call clinical sites in your area; explain that you are applying to a OTA Program and that you would like to observe either an OT or an OTA at their facility. Can I work and still go thru the program? It is possible for a student to work part-time while in the program, however it is not advised due to the intense nature of the program. Each semester, the student will carry a full load and a grade of 75 or higher must be achieved in order to pass each class. This along with the clinical work that is off-campus (possibly out of town) will not be changed to accommodate a work schedule. Depending on the instructor you may have to meet in the evenings rather than earlier in the day. What are the typical hours while in the program? The OTA program classes are full-time and vary on days and times each semester. During the first 3 semesters of the technical program, expect to be in class Monday thru Thursday (some Fridays) 8+ hours per day. Typical hours during the first 3 semesters vary and may start as early as 9:00am and end as early as 5:00pm or as late as 9:00pm. Times vary per semester, however the last semester the student must attend off-campus clinical rotations that require Monday thru Friday, 40 hours per week for 16 weeks. Can I be guaranteed that all of my clinical rotation sites will be in my hometown? Unfortunately, the answer is no. Each student will have 2 clinical rotations. The clinical rotations are two 8-week clinical rotations completed in the Fall Semester prior to graduation. Because of the limited availability of sites that are in town, we cannot guarantee one student over another that you will not have to travel to complete the clinical rotations. Are the costs incurred during clinical rotations covered in our tuition? Again, the answer is no. Each student is obligated to cover the expenses out of pocket. However, the clinical coordinator will work with each student on an individual basis to try to place the student in an area that will require the least expense. (i.e. This may be in a town where the individual has relatives or friends and the cost would be minimal to the student) How long is the program? The degree is designed to be completed in 2 years. If the student has already completed the pre-requisite coursework while at Darton or another institution, the professional phase of the OTA coursework can be completed in 16 months; however, this varies based on the individual student due to the length of time to complete all necessary coursework prior to applying. Once accepted into the OTA program, 4 semesters (16 months) of the professional phase beginning Fall of every year and ending the following Fall Semester for graduation in December must be taken in sequence. I already have a degree; do I have to complete all of the prerequisites? Yes, all of the prerequisites must be completed. Chances are, you have already completed most of the prerequisites, and those classes may be transferred into Darton State College to count toward the degree. You may transfer credits from other institutions, but suitability for transfer will only be decided by the Registrar of Darton State College. In order to determine if your previous college coursework is eligible for transfer, you must complete an application to become a student at Darton State College (http://www.darton.edu/admin/admissions/) and have all of your previous coursework in the form of a transcript sent from the other institution to the Darton State College Registrar. She will evaluate your transcripts and send you a letter indicating what is eligible and what is not. Do I have to take Anatomy & Physiology I & II or may I substitute those 2 courses with the one course offered from Darton State College (Anatomy & Physiology for the Healthcare Professional)? Darton State College does offer an acceptable substitution for the anatomy series, however, please note that we recommend the series over the one course. If you ever plan to continue your education after Darton State College, the 2 course series is a must. The course is acceptable for the OTA Program, but it will not transfer out of Darton State College to count toward any future degree at another institution.

I want to eventually become an OT, but am I right in using the OTA program as a stepping-stone to achieving this goal. No, the OTA program is NOT a stepping-stone to OT school and seats in the Darton State College OTA program are not used as such. Students wishing to become an Occupational Therapist must first complete 3-yr. of core curriculum classes then apply for admission to a Masters-level Occupational Therapy Program. Obtaining an Associate Degree in OTA first is neither necessary nor common. In order to become a Occupational Therapist, a student must complete a graduate level program in Occupational Therapy. In Georgia, there are two institutions that offer a graduate degree in physical therapy: Georgia Regents University (Augusta) and Brenau University (Gainesville). For a more complete description of the pre-requisite requirements and application/selection process utilized by those programs, we encourage you to review the website of each OT Program in Georgia and contact those faculty advisors/instructors with questions. Please be aware that the OTA Program at Darton State College and the OT Programs in Georgia are in no way linked or affiliated. There is no shortcut toward achieving a degree in Occupational Therapy. Additionally, please be aware that graduates of the Darton OTA Program are not given preference in the selection process for any OT Program and the journey to becoming an OT would be much longer. I have observed under a Special Education teacher or other health professional. Can I include these hours and have them count toward the OTA observational hours? No, these hours are specifically designed to give the applicant a better understanding of the role of OTs and OTAs in patient care. Although the hours may assist the student in discerning between the path of occupational therapy vs. other health care fields, no hours outside of occupational therapy will count. When is the deadline for application? June 1 st of every year with a new class beginning each Fall Semester. Where can I learn more about occupational therapy? The American Occupational Therapy Association (www.aota.org)

DARTON STATE COLLEGE Occupational Therapist Assistant Program Application *Photocopying is permitted. CONTACT INFORMATION Last Name First Name Middle Initial Preferred Name (if different) Date of Birth *PLEASE PRINT Current Street Address or Apartment Number or P.O. Box City, State Zip code Permanent Street Address or Apartment Number or P.O. Box City, State Zip code E-mail (*please give the one you most frequently check) Cell # Darton Student ID# EDUCATIONAL BACKGROUND High School Name City, State Date of Graduation or GED (1) College / University Name City, State Degree Received? Please Circle: Yes No Dates Attended Degree & Major (if applicable) (2) College / University Name City, State Degree Received? Please Circle: Yes No Dates Attended Degree & Major (if applicable) (3) College / University Name City, State Degree Received? Please Circle: Yes No Dates Attended Degree & Major (if applicable) GRADE POINT AVERAGES 1. Use the Prerequisite G.P.A. Form to calculate your prerequisite grade point average and include the completed form with the application. (Record the prerequisite G.P.A. in the box) Prerequisite G.P.A. 2. Use the Cumulative G.P.A. Form to calculate your overall grade point average or the G.P.A. for only the last 40 hours earned and include the completed form with the application. Indicate the additional G.P.A. you choose to include by only filling in the box for either cumulative G.P.A. or last 40 hours earned. Cumulative G.P.A. Last 40 hrs G.P.A. OBSERVATIONAL HOURS Please include the verified/signed documentation of hours with the application, as well as completing the boxes below with specific number of hours each setting and the total number of hours accumulated. Name of Facility Type of Setting/s (ie. Acute care, outpatient, rehab unit, nursing home, pediatrics, aquatic, home health, wound care, etc.) Number of hours in each setting (be specific) in TOTAL =

ESSAY *No specific length is required Please include a hand written essay explaining why you have chosen OTA as a career path and why you feel you deserve a seat in the class. RECOMMENDATION *May be mailed separately Please include at least two completed recommendation forms from an OT or OTA. (The Letter of Recommendation Form is required.) SIGNATURE Have you previously applied to this program? Yes No If yes, when? I hereby apply for admission to the OTA Program for the Fall Semester and certify this application is correct and complete. I have read the application packet, including the essential abilities required and understand the application and selection processes. I further understand that any failure on my part to comply with these processes will result in the cancellation of my application. I am also aware of the competitive nature of the application process for the OTA program and therefore understand that taking prerequisite courses, as well as meeting all of the minimum requirements does not guarantee acceptance into the program. Signature of Applicant Date Please mail the completed application along with the following documents to the address below. Darton State College c/o OTA - Health Sciences Division 2400 Gillionville Road Albany, GA 31707-3098 (1) If you wish to know if your application has been received, please send the application as certified mail. The OTA Selection Committee will not open any mail until after the deadline or answer calls/emails; therefore, calling to inquire about the status of the application will be useless. (2) Again, the OTA Selection Committee will not open any mail until after the deadline or answer calls/emails regarding application status; therefore, if you wish to know if your application is complete, please read all directions and utilize the checklist below. Prerequisite G.P.A. Form Must be completed even if courses are still in progress. Cumulative G.P.A. Form (or last 40 hours completed) Must be completed even if courses are still in progress. Observational Hours Form Other form of documentation of hours is acceptable. Recommendation Forms The Recommendation Forms within this packet are required. May be mailed separately from the application by the OT or OTA. Hand written essay No specific length is required. Application completed and mailed before June 1 Sent certified and checklist completed Please note: No application fee is required for the OTA program. The application and admission process for Darton State College is separate from the OTA program application.

Instructions for G.P.A. Forms The G.P.A. forms MUST BE COMPLETED & mailed with your application. If you do not have a grade for a course at the time the form is completed, do not include the number of credit hours or quality points in the (QH) or (QP) columns; simply place an X in the boxes (QH) and (QP). Please indicate in the grade column if the course is in progress or indicate when you plan to take the course. An example of how to calculate a G.P.A. has been provided below. Utilize the Prerequisite G.P.A. Form at the bottom of this page and the Cumulative G.P.A. Form to calculate your grade point averages and record the averages on Page 1 of the application. Where Course Was Completed Course Identification QH number of credit hours per course Multiply Letter Grade & Equivalent Values A=4, B=3, C=2, D=1, F=0 equals (QH) x Grade Equivalent = (QP) Quality Points Columbus State ENGL 1101 3 x A (4) = 3 x 4 = 12 Columbus State MATH 1111 3 x B (3) = 3 x 3 = 9 Darton POLS 1101 3 x A (4) = 3 x 4 =12 Darton MUSC 1100 3 x C (2) = 3 x 2 = 6 Darton PSYC 2103 3 x B (3) = 3 x 3 = 9 Darton BIOL 2111K 4 x B (3) = 4 x 3 = 12 Darton BIOL 2112K 4 x B (3) = 4 x 3 = 12 Darton BIOL 2115K X x X in progress = X Total QH: 23 Total QP: 72 72 QP 23 QH = 3.13 GPA 1. Once all information has been placed in the appropriate column, total the QH column (number of credit hours QH) for the courses that have been completed. If a grade has not been earned, simply place an X in the QH column for that course. 2. The equivalent value must be assigned for the grade earned for the course. If you earn an A, then it is equivalent to a 4, and so on. (A=4, B=3, C=2, D=1, F=0) If a grade has not been earned, simply place an X in the QP column for that course. 3. Calculate the QP for each course by multiplying number of credit hours (QH) by the equivalent value of the grade earned for the class. 4. Total the last column, quality points/qp, and then complete the formula Total QP Total QH = G.P.A 5. Complete the Prerequisite G.P.A. Form below and the Cumulative G.P.A. Form and record averages on Page 1 of the application. 6. Your Cumulative/Overall G.P.A. includes ALL coursework/college credits previously taken at one or multiple institutions. ALL includes grades earned in every course you have taken, including the repeated courses. You also have the option of only calculating the last 40 credit hours completed, but you do not include both. The option to calculate and include only the last 40 hours completed is a means of forgiveness for anyone that may have lost focus in his/her earlier years in college. Prerequisite G.P.A. Form Where Course Was Completed Course Identification QH number of credit hours per course Multiply Letter Grade & Equivalent Values A=4, B=3, C=2, D=1, F=0 equals (QH) x Grade Equivalent = (QP) Quality Points Total QH: Total QP: Total QP Total QH = Prerequisite G.P.A

Cumulative G.P.A. Form (OR the Last 40 hours completed) Where Course Was Completed Course Identification QH number of credit hours per course Multiply Letter Grade & Equivalent Values A=4, B=3, C=2, D=1, F=0 equals (QH) x Grade Equivalent = (QP) Quality Points Total QH: Total QP: Total QP Total QH = Prerequisite G.P.A *If additional rows are needed, please make another copy of this sheet to complete your needs and staple together.

DARTON STATE COLLEGE Occupational Therapy Assistant Program Observational Hours Form Name of Applicant: Phone Number: To the Clinician: The above named is applying to the Occupational Therapy Assistant program at Darton State College. The applicant must complete a minimum of 40 hours of observation in any type of occupational therapy setting such as a hospital, skilled nursing facility, outpatient facility, etc. The clinical observation hours are designed to give the applicant a better understanding of the role of OTs and OTAs in patient care. Thank you for educating potential students about the profession. To the Applicant: You may also use other forms of documentation for your hours. If you worked at the facility, you may include a copy of your hours from payroll dept., etc. Please make sure you total your hours and write a total number of all of your hours on the application. It is your responsibility that the documentation is completed and returned before the deadline of June 1 st. Duplicate copies of this form are permitted. Type of facility Facility Observation Hours OT/OTA Signature Name Date Time Time In Out Hours *must be a licensed OT or OTA Hospital Healing Hands Hospital 4/21/11 8:00 am 1:00 pm 5.0 Any Therapist, OT Out-patient Any Out-patient Facility 4/28/11 10:00 am 12:00 pm 2.0 Any Therapist, OTA

DARTON STATE COLLEGE Occupational Therapy Assistant Program Recommendation Form Name of Applicant: (Print legibly) Dear Applicant, Please sign below to acknowledge the following statement: I hereby waive my right to access this letter of recommendation. This letter will remain confidential to encourage the recommender to provide a candid assessment. I understand that a personal letter of recommendation from a friend or family member is unacceptable. Applicant s Signature Date _ OT or OTA: Please indicate in what capacity you know the applicant by checking the appropriate box below. I do not know the applicant outside of the observational experience. I know the applicant outside of the observational experience. Please indicate how long you have known the applicant and in what capacity: Please rank the applicant in relation to the observational volunteer or work experience. Outstanding Excellent Good Average Poor N/A Communication Skills Effective Use of Time Professionalism Responsibility Critical Thinking Stress Management **Please comment on the characteristics that will make the applicant a competitive candidate for the OTA Program. Comments: Overall, I rate this applicant: Outstanding (Top 1%) Excellent (Next 5%) Good (Next 10%) Average (Next 25%) Poor (Remaining %) This form must be received no later than June 1. Please mail to: Darton State College: Health Sciences Division Attn: OTA Selection Committee 2400 Gillionville Road Albany, GA 31707-3098 Signature Please circle: OT OTA How many years have you practiced? _ Printed Name Date Organization/Clinic _ *Any questions, comments, or concerns, please call the Program Director, Dr. Jeff Etheridge @ 229-317-6908.

DARTON STATE COLLEGE Occupational Therapy Assistant Program Recommendation Form Name of Applicant: (Print legibly) Dear Applicant, Please sign below to acknowledge the following statement: I hereby waive my right to access this letter of recommendation. This letter will remain confidential to encourage the recommender to provide a candid assessment. I understand that a personal letter of recommendation from a friend or family member is unacceptable. Applicant s Signature Date _ OT or OTA: Please indicate in what capacity you know the applicant by checking the appropriate box below. I do not know the applicant outside of the observational experience. I know the applicant outside of the observational experience. Please indicate how long you have known the applicant and in what capacity: Please rank the applicant in relation to the observational volunteer or work experience. Outstanding Excellent Good Average Poor N/A Communication Skills Effective Use of Time Professionalism Responsibility Critical Thinking Stress Management **Please comment on the characteristics that will make the applicant a competitive candidate for the OTA Program. Comments: Overall, I rate this applicant: Outstanding (Top 1%) Excellent (Next 5%) Good (Next 10%) Average (Next 25%) Poor (Remaining %) This form must be received no later than June 1. Please mail to: Darton State College: Health Sciences Division Attn: OTA Selection Committee 2400 Gillionville Road Albany, GA 31707-3098 Signature Please circle: OT OTA How many years have you practiced? _ Printed Name Date Organization/Clinic _ *Any questions, comments, or concerns, please call the Program Director, Dr. Jeff Etheridge @ 229-317-6908.

DARTON STATE COLLEGE Occupational Therapy Assistant Program CERTIFICATE OF IMMUNIZATION Part A To be completed by student. Name Last First Middle Initial Date of Birth Student ID # Address Street City State Zip Daytime Telephone Number ( ) Part B To be completed by a health care provider. Dates must include month and year. I. MMR (Measles, Mumps, Rubella) Note: Date must be after 1970 1. Dose 1 immunized at 12 months of age or later, and (m/d/y) / _/ 2. Dose 2 immunized at least 30 days after Dose 1 (m/d/y) / _/ II. Measles Note: Date must be after March 4, 1963 1. Had disease, confirmed by physician diagnosis in office record, OR (m/d/y) 2. Born before 1957 and therefore, considered immune, OR (m/d/y) 3. Has laboratory evidence of immune titer (specify date of titer), OR (m/d/y) 4. Immunized with live measles vaccine at 12 months of age or later, AND (m/d/y) 4a. Immunized with 2 nd dose of live measles vaccine at least 30 days after 1 st dose (m/d/y) AND III. Mumps Note: Date must be after April 22, 1971 1. Had disease, confirmed by physician diagnosis in office record, OR (m/d/y) 2. Born before 1957 and therefore, considered immune, OR (m/d/y) 3. Has laboratory evidence of immune titer (specify date of titer), OR (m/d/y) 4. Immunized with live measles vaccine at 12 months of age or later (m/d/y) AND IV. Rubella Note: Date must be after June 9, 1969 1. Has laboratory evidence of immune titer (specify date of titer), OR (m/d/y) 2. Immunized with vaccine at 12 months of age or later (m/d/y) / _/ / / / / / / / / / _/ / _/ / _/ / / / _/ / _/ V. PPD 5TU Note: Within 3 months of program entry date (m/d/y) / / VI. Chest X-ray Note: Necessary only if PPD is positive (m/d/y) / / VII. Polio Note: Minimum of 3. Trivalent OPV up to 18 years (m/d/y) / / of age. After 18, OPV is not recommended. (m/d/y) / / VIII. Hepatitis Note: After above requirements are completed 1. Had disease, confirmed by physician diagnosis in office record, OR (m/d/y) 2. Has laboratory evidence of immune titer (specify date of titer), OR (m/d/y) 3. Has complete immunization series (m/d/y) (m/d/y) (m/d/y) / _/ / _/ / / / / / _/ _ Signature of Physician or Health Department Official Print Name/Facility Date

DARTON STATE COLLEGE Occupational Therapy Assistant Program DARTON STATE COLLEGE FEES AND COSTS All fees are payable at the beginning of each semester and registration is not complete until these fees have been paid. Payment must be made by cash, check, money order or credit card (cash advance to which bank will add interest and service charge). For a complete listing of fees and costs, see Financial Information Section of the Darton State College Catalog. ADDITIONAL FEES Hepatitis B Vaccination Fees- Each student enrolled in the Occupational Therapy Assistant program is required to receive vaccination against the Hepatitis B virus. Students who have already had the series of vaccinations are required to provide substantiating documentation. It is the responsibility of the student applicant to schedule and pay the cost of this vaccination. The student may elect to utilize the services of the County Health Department or family physician to complete the vaccination process. Malpractice Insurance- Students are required to obtain malpractice insurance their first semester in the program. This insurance is included in the fees of the Fall Semester of each in-coming class. The cost of the insurance is approximately $17.50. Professional Fees- Students enrolled in the Occupational Therapy Assistant program are expected to become active members in both National, State and regional professional organizations as well as the Student Occupational Therapy Association. The fees for these organizations are listed below: American Occupational Therapy Association Student Membership $75.00 Georgia Occupational Therapy Association Student Membership $25.00 Lab Equipment- Relevant goniometric measuring equipment, blood pressure cuff and stethoscope, and lab items related to patient skills are required. Lab coats and other professional attire may be necessary based upon the requirements of the fieldwork sites. Name Badges- Students are required to purchase name badges from the Health Sciences Department at Darton State College prior to Level I fieldwork. Cost is approximately $10.00. Background Check- Students are required to have a background check as required by fieldwork sites. Students are required to have the background check completed prior to Level I fieldwork. Cost is approximately $50.00. Drug Screening- Some fieldwork sites may require that the student complete a drug screening prior to a fieldwork rotation. Students will be expected to schedule, complete, and pay for this requirement. Cost is approximately $50.00. Test Fee- Each semester approximately $145 will be tagged to one course. Upon completion of the program, these funds will be paid to NBCOT for you certification exam. During the summer semester, $25 will be tagged to one course to pay for the Occupational Therapy Knowledge Exam (OTKE). The OTKE is a practice test for the NBCOT.