Reinstatement Application

Reinstatement Application

Submit this application only if your certification has already expired. A certificate that has expired may be reinstated up to two years following the expiration date*.

*For certifications that expired prior to August 1, 2016, RESNA will allow a one-year grace period for these individuals to reinstate their certification, ending August 1, 2017. The CEU penalty will be capped at 2.0 CEUs. Through August 1, 2017, RESNA will offer a discounted reinstatement fee of $175 instead of the normal reinstatement fee of $250.

Send application and education documentation with payment of the Reinstatement fee to RESNA at:

1560 Wilson Blvd OR OR (fax) 703-524-6630

Suite 850

Rosslyn, VA 22209 To avoid duplicate charges, submit your application just one time. Retain a copy for your records.

Provide your name and contact information so that RESNA mailings and updates are sent to the correct address.

Your preferred address information will be listed in the online ATP directory.

Name: Job Title:
Organization Name:
Business address street:
Business City, State & Zip Code:
Home address street:
Home City, State & Zip Code:
Email: Fax:
Work Phone: ext: Home phone: Cell phone:
Preferred address for RESNA mailings and Directory listing: Business Home
Do you currently offer direct, consumer-related AT services? Yes No

Indicate payment method of the Reinstatement fee ($175) (Note: fee returns to $250 on August 2, 2017)

Check Enclosed (make payable to RESNA) Check number:
Credit Card Number: Visa/MasterCard:
Card Expiration Date: 3-Digit Security code on back of card:
Name on Card:
Card Billing Address Street:
Card Billing Address City, State & Zip Code:
Signature:
Name
First / Middle / Last / Maiden/Other
Employer /
Employer Phone / Employment Dates
Job Title /

Describe below your responsibilities relating to assistive technology service provision.

(Document at least .25 FTE; 1 FTE = 35-40 hrs/week of work in AT during the two years immediately prior to your submitting this application. If you worked for multiple employers, photocopy this form and submit one for each employer.)

Percentage of time spent in AT services in this position = %

Signature

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.

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
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
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
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
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.
To the best of my knowledge and belief I am in compliance with the RESNA Code of
Ethics and Standards of Practice.
Signature / Date

Continuing Education Requirements for Reinstatement

You must satisfy the regular continuing education requirement for certification renewal PLUS a reinstatement penalty based on your certification expiration date. Education must be related to the provision of assistive technology to persons with disabilities.

Continuing education requirement for certification renewal:

To satisfy the Professional Development requirement, you must document:

20 hours of AT-related training (in-person and/or online courses, seminars, and workshops), to include:

1.0 CEU (10 hours) minimum; AND

10 CECs / contact hours or additional CEUs

two AT-related academic credit hours at a recognized academic institution of higher education

CEUs (continuing education units) will be accepted from IACET-accredited providers, professional associations (i.e. RESNA, APTA, ASHA, AOTA), academic institutions, and state licensing boards. The certificate of attendance must list the attendee's name, the name of the course, the dates of the course, and the speaker/sponsor signature. The certificate must also indicate the number of CEUs earned; otherwise the course will be counted as contact hours instead of CEUs.

Up to 10 contact hours (sometimes measured as CECs) are allowed for training that isn’t approved by IACET, a professional society, an academic institution, or a state licensing board. The certificate of attendance for a training session must include the attendee's name, the date(s) and length (in hours) of the course, and the speaker/sponsor signature. A maximum of 3 hours of in-service product training per year will be accepted as contact hours. (If you are submitting in-service training, then you must use the “In-Service Training Form” in this application.)

Reinstatement Penalty

Documentation of an additional 0.25 CEUs is required for each quarter (three-month period) that follows after the certification expiration date. The maximum CEU penalty will be 2.0 CEUs.

For example, if a certification expires June 30, 2017, and the reinstatement application is submitted in July 2018, then the certification has been expired for four quarters, and the following CEU penalty would apply:

July 1 – September 30, 2017: 0.25 CEU

October 1 – Dec 31, 2017: 0.25 CEU

January 1 – March 30 2018: 0.25 CEU

April 1 – June 2018: 0.25 CEU

Total Penalty: 1.00 CEU (four quarters x 0.25 CEUs = 1.0 CEU)

My certification expiration date:

Number of quarters (3 months) passed since termed certification:

Number of quarters x .25 CEUs: Calculated PENALTY (Maximum 2.0 CEUs)

Documentation of Continuing Education Activities

Total number of hours required:

20 hours regular certification renewal requirement + (calculated PENALTY X 10) =

Example: 20 hours regular certification renewal requirement + (1.00 PENALTY x 10)

20 hours regular certification renewal requirement + 10 = 30 hours

Total number of CEUs that must be included in the continuing education hours above:

1.0 CEU regular certification renewal requirement + calculated PENALTY =

Example: 1.0 CEU regular certification renewal requirement + 1.00 calculated PENALTY = 2.0 CEUs

Affidavit and Record of AT-Related Continuing Education

(Attach all certificates of attendance with this application)

Course Title / Sponsor / # credits earned / Credit type* / Date(s)
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other
CEU other

*Credit type: “Other” includes non-CEU credits such as contact hours, CECs, etc.

Total credits on this page: Total CEUs on this page:

Make photocopies of this page and attach as necessary.

Use this form if you plan to apply in-service training towards the RESNA recertification requirement.

Complete on “In-service Training Form” for each in-service training event. You may apply up to 3 contact hours of in-service training annually towards the recertification requirements

Name of Attendee

Date of in-service

Presenter

Product Demonstrated

Number of minutes

Manufacturer in-service
Lecture
Demonstration
Product trial

Learning Objectives:

1
2
3
4
Presenter Signature
Presenter’s employer
Presenter’s title
Date

Profile Information

What is your primary professional setting (Check only one):

Academic institution (post-secondary education)

Academic institution (primary or secondary education)

Acute care hospital

Community-based center, i.e. independent living center, AT specialty center

Complex Rehabilitation Technology (CRT) supplier/provider

Durable Medical Equipment (DME supplier/provider)

Health system or hospital-based outpatient facility or clinic

Industry/Manufacturer

Inpatient rehab facility

Government funded agency

Patient's home/home care

Private outpatient office or private practice

Research center

Retail AT supplier

Skilled nursing facility/long term care facility

Other, specify:

AT Practice Specialty Area (Check all that apply):

Architectural Accessibility & Universal Design

Cognition & Learning

Computer Access & Applications

Communication

Employment & Workplace Modifications

Environmental & Personal Aids for Daily Living

Hearing

Orthotics

Personal Robotics

Prosthetics

Recreation, Leisure & Sports

Seating, Positioning & Mobility

Tele-rehab & Tele-monitoring

Transportation & Driving

Vision

Other, specify:

No AT practice specialty

Years worked in your professional area?

2 years or less 3 to 6 years 7 to 10 years 11 years or more

Most Relevant Academic/Professional Training (Check all that apply):

Audiologist

Assistive Technologist

Attorney

Biomedical Engineer

Building Trades

Computer Science

Counseling

Electrical Engineer

Ergonomist

Educator, General Ed

Educator, Special Ed

Industrial Engineer

Mechanical Engineer

Mechanical Maintenance

Nurse

Occupational Therapist

OT Assistant

Orthotist

Physician

Physical Therapist

PT Assistant

Prosthetist

Psychologist

Rehabilitation Engineer

Social Worker

Speech & Language Pathologist

Technician

Other, specify

Highest Education Level Achieved

HS Diploma or GED

Associate Degree in Non-Rehab Science

Associate Degree in Rehab Science

Bachelor’s Degree in Non-Rehab Science

Bachelor’s Degree in Rehab Science

Bachelor’s Degree in Special Education

Master’s Degree or higher in Rehab Science

Master’s Degree or higher in Special Education

Are you a student presently?

Yes No

What is your primary role in the AT field? (Check only one)

Service provider (e.g., evaluates users' abilities and needs; identifies and specifies AT and environmental solutions, manages service delivery processes, trains in the use of technology)

Technology Supplier (e.g., assesses user and devices; selects, orders, configures, customizes, designs, fabricates and sells commercial and non-commercial AT devices)

Manufacturer (e.g., designs, develops, tests, packages, distributes, resells, and markets commercial AT devices and software)

Educator of AT Professionals

Educator, e.g. pre-school, K-12, university, trade, etc.

Researcher

Resource Provider, e.g. information & referral, demonstration/loan/reuse programs, advocacy, funder, etc.

Other, specify

What other roles do you perform in the AT field? (Check all that apply)

Service provider (e.g., evaluates users' abilities and needs; identifies and specifies AT and environmental solutions, manages service delivery processes, trains in the use of technology)

Technology Supplier (e.g., assesses user and devices; selects, orders, configures, customizes, designs, fabricates and sells commercial and non-commercial AT devices)

Manufacturer (e.g., designs, develops, tests, packages, distributes, resells, and markets commercial AT devices and software)

Educator of AT Professionals

Educator, e.g. pre-school, K-12, university, trade, etc.

Researcher

Resource Provider, e.g. information & referral, demonstration/loan/reuse programs, advocacy, funder, etc.

Other, specify

Professional Credentials/Licenses Held (Check all that apply)

ATP *

CPE

CRC

CRTS

LCSW

MD/DO

OTA

PTA

RET *

RRTS

SLP

SMS *

None

Other

Member Organizations Other th an RESNA (Check all that apply)

AAA

ACM

AOTA

APTA

ASHA

ASME

ATA

BMES

HFES

IEEE

NRRTS

TASH

Other, specify

None