Volunteer Hours Verification — online

KENT STATE UNIVERSITY AT EAST LIVERPOOL 
OCCUPATIONAL THERAPY ASSISTANT TECHNOLOGY 
VOLUNTEER HOURS VERIFICATION FORM   

This form is to be completed by a licensed Occupational Therapist, or Occupational Therapy Assistant. 

Forms completed by anyone other than an OT or OTA will not be accepted. Volunteer experiences cannot be evaluated by a relative or personal friend. Please present this form to your supervising therapist with a stamped envelope addressed to the OTA Program.  The total number of required hours is 40, divided between 2 different sites, 20 hours each. Please complete the next section completely.

I. APPLICANT:

A. Applicant’s Name            

B. Facility Name & Address

C. Facility Phone Number  
 
D. Number of Hours Completed                    

E. Please sign the following waiver prior to giving this form to the supervising therapist.
       
        I waive the right to view this completed form in order to afford an unbiased evaluation by the supervising therapist.

               Signed:  _________________________________________________

II. OCCUPATIONAL THERAPY PRACTITIONER:

Please rate the applicant on the following behavioral characteristics:

Please understand that the Admissions Committee relies heavily on your observations and input. We appreciate any insights you have to offer. Indicate the level of your overall endorsement of the candidate.

    _______       Highly recommended                 
    _______       Recommended                  
    _______       Recommend with reservation      
    _______       Not recommended

Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Printed Name of Evaluator: ____________________________________________________________________

Signature ____________________________________________________ State & License No. ________________

Date ___________

PLEASE NOTE: VOLUNTEER HOURS WILL NOT BE ACCEPTED IF MORE THAN TWO YEARS OLD.

PLEASE MAIL TO:
Harriett S. Bynum, MS, OTR/L 
Occupational Therapy Assistant Program
Kent State University
East Liverpool Campus
400 East Fourth St.
East Liverpool, OH  43920

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