1. health and fitness

2015 Application for Renewal of Registration
Renewal Deadline: May 31, 2015
Please refer to the online Renewal Guide at http://www.cotm.ca/index.php/registration/renewal for more information or
contact the office with questions.
1. MEMBERSHIP STATUS: Select the appropriate renewal status for COTM and/or MSOT, and complete the sections indicated.
COTM Renewal Status
Complete Sections
MSOT Renewal Status
Complete Sections
 Renew as Practising
1,2,3,4,5,6,7,8,9,10,11,13,15
 Join as a Full Member
1,2,13,14,15
 Renew as Provisional
1,2,3,4,5,6,7,8,9,10,11,13,15
 Join as Associate (Retired) Member 1,2,12,14,15
 Renew as Non-Practising
1,2,3,4,5a,7,8,9,10,11,15
 Join as Out of Province Member
1,2,12,14,15
 Resignation of Registration
1,2,4,12
 Continue Life Membership
1,2,12,14,15
2. DEMOGRAPHICS: Indicate necessary changes to demographic information below and complete blanks.
Name:
Member #:
Full Address:
City:
Province:
Postal Code:
Email:
Home Phone:
Work Phone:
3. EDUCATION UPDATES: Only complete if reporting new information. Submit a photocopy of any new degree(s).
a) Designation:
 Certificate/Diploma
 Research (thesis-based) Masters
 Bachelors
 Professional (course-based) Masters
 Doctorate
b) Details: Title of Degree/Certificate/Diploma _____________________________________________________________________
Major Field ____________________________________________________________
Year of Graduation _______________
School ________________________________________________________________
Province/Country _________________
4. OT EMPLOYMENT HISTORY: Provide details for where you worked JUNE 1/2014 – MAY 31/2015
The COTM currency requirement as per The Occupational Therapists Regulation is for 700 hours of practice in the three
year period preceding the date of application for registration or renewal of registration. We ask you to provide us with your
worked hours in the one year period (June1, 2014 to May 31, 2015) in order to conduct our review of your practice hours to
determine if you meet the 3 year currency requirement
a) Check all of the following items that apply:





NOTE: Please see online notice
i) I worked at least 700 hours during this period (Provide details in section b)
regarding pending changes to hours
ii) I have changed employers during this period (Provide details in section b)
and currency requirements.
iii) I have not worked at least 700 hours this period (Provide details in section b)
iv) I was on leave of absence for more than 3 months (Provide dates in section b)
v) My work included education or volunteer hours (Provide details in section b and attach proof)
b) If applicable, provide details for your previous registration year’s work. If more space is required, attach a separate sheet to your form.
Worksite
Address (including postal code)
In calculating “total hours worked” subtract vacation days, sick days, leave of absence, etc.
Dates of Employment
Total hours worked
(if less than 700)
Total Hours
(if less than 700)
FAILURE TO SUB MIT ALL DOCUMENTS FOR COTM RENEW AL BY MAY 31, 201 5** W ILL RESULT IN A LATE FEE
5. CURRENT OT EMPLOYMENT IN MANITOBA: Provide details for your work situation AS OF JUNE 1/2015
a) Choose one of the following descriptions that best suits your current work situation, then proceed as instructed.





Working as an occupational therapist. (Please complete parts b &c of this section)
Unemployed and not seeking employment in occupational therapy. (Proceed to section 7)
Unemployed and seeking employment in occupational therapy. (Proceed to section 7)
Employed, but on leave of absence such as parental leave. (Proceed to section 7)
Employed, but not as an O.T. (Proceed to section 7)
b) Complete all fields for each employer. If more space is required, please attach a separate sheet to your form.
Employer
Scheduled Hours
Work Phone
Address of Employer including postal code
Primary
□ Check here if same as in section 4
Secondary
□ Check here if same as in section 4
Tertiary
□ Check here if same as in section 4
[Primary - Most hours], [Secondary - Less hours], [Tertiary - Least hours]. If you have additional employers, attach a separate sheet to your renewal form.
c) Complete all fields for each employer. See the Renewal Guide - Statistics if clarification is required.
Is the postal code for the employer the same as the postal code for your worksite? (worksite = where service is delivered)
Primary site
□ yes □ no
Secondary site
□ yes □ no
Tertiary site
□ yes □ no
Employment Category (indicate one for each employment)
Primary Employment
□□
10 Permanent
20 Temporary
Secondary Employment
□□
30 Casual
Tertiary Employment
□□
Tertiary Employment
□□
Tertiary Employment
□□
40 Self-Employed
Full/Part time Status (indicate one for each employment)
Primary Employment
□□
10 Full time
20 Part time/Casual part time
Secondary Employment
□□
Position (indicate one for each employment)
Primary Employment
10 Manager
□□
Secondary Employment
20 Professional leader/ Coordinator
□□
30 Direct Service Provider
40 Educator
50 Researcher
60 Other
Employer Type (indicate one employer type for each employment)
Primary Employment
010
020
030
040
050
□□□
Secondary Employment
General Hospital
Rehabilitation Facility
Mental Health Hospital/Facility
Residential Care Facility
Assisted Living Residence
060
070
080
090
100
□□□
Community Health Centre
Visiting Agency/ Business
Group Professional Practice/Clinic
Solo Professional practice/Business
Post-Secondary Educational Institute
Tertiary Employment
110
120
130
140
□□□
School or School Board
Assoc/Gov’t /Para-Government
Industry/Manufacturing & Commercial
Other Employer type, not described
Area of Practice (indicate one for each employment)
Primary Employment
010
020
030
040
050
□□□
Secondary Employment
Mental Health
Neurological System
Musculoskeletal System
Cardiovascular & Respiratory
Digestive/Metabolic/Endocrine
01
06
□□
General Physical Health
Vocational Rehabilitation
Palliative Care
Health Promotion & Wellness
Other areas of Direct Service
Tertiary Employment
□□□
Service Administration
Client Service Management
Medical/Legal related Client Service Management
Teaching
Research
160 Other Area of Practice
Geographical Area of Service Provision (indicate one for each employment) Map to RHA’s in Manitoba: -http://www.rham.mb.ca/rhaMap.html
Primary Employment
060
070
080
090
100
□□□
Secondary Employment
Winnipeg
Mixed
02
07
Prairie Mountain Health
Manitoba
03
08
110
120
130
140
150
□□
Tertiary Employment
Southern Health
Out of Province
04 Interlake Eastern
05
□□
Northern
Client Age Range
Primary Employment
10
41
□□
Secondary Employment
Preschool age
Mixed Adults
20
44
School age
All Ages
21
98
□□
Tertiary Employment
Mixed Pediatrics
Not working with clients
30
□□
Adults 18-64
40
Seniors 65+
Funding Source (indicate funding source for each employment)
Primary Employment
10
Public Government
□□
Secondary Employment
20
Private Sector / Individual Client
□□
30
Tertiary Employment
Public / Private mix
40
□□
Other funding source
FAILURE TO SUB MIT ALL DOCUMENTS FOR COTM RENEW AL BY MAY 31, 201 5** W ILL RESULT IN A LATE FEE
6. LIABILITY INSURANCE: This section must be completed if renewing with COTM as ‘practising’ or ‘provisional’.
As per The Occupational Therapists Regulation, Section 18:
“Every occupational therapist who provides clinical services shall obtain or be covered by, and maintain, liability insurance
coverage to a minimum of $5,000,000.00.”
Indicate the type(s) of coverage you hold:





CAOT Insurance: expiry date _________________________ - Original insurance certificate required with renewal
Other Insurance: expiry date _________________________ - Original insurance certificate required with renewal
Employer Insurance: covered by HIROC or HED (please specify) _______________________________________________
Other Employer Insurance - Verification letter required with renewal
The nature of my practice does not necessitate liability insurance
Remember: It is your r esp onsibility to maintain professional liabilit y insu rance cover age
for all relevan t areas of pr actice.
7. PROFESSIONAL REGISTRATION (As of June 1, 2015): Answer the question, and provide details if required.
Are you registered to practise occupational therapy in another province or country?
Yes  (provide details and proof)
Regulatory Organization
Province/State and Country
No 
License/Registration #
8. REGISTRATION IN OTHER REGULATED PROFESSIONS (As of June 1, 2015): Answer the question, and provide details if required.
Are you registered to practise in another profession in Manitoba or elsewhere?
Yes  (provide details and proof) No 
Check here if permanent registration certificate has already been submitted to COTM, then skip to Section 9 
Regulatory Organization
Province/State and Country
License/Registration #
9. HISTORY and CONDUCT: Answer the following questions, and provide details if required.
Do you have a physical or mental condition, disorder or addiction to alcohol or drugs that interferes with your ability
to practise occupational therapy?
Yes  No 
Have you been refused registration by an O.T. regulatory organization since June 1, 2014?
Yes  No 
Have you had a finding of, or are you currently facing a proceeding for professional misconduct, incompetence,
incapacity or a similar issue in another jurisdiction?
Yes  No 
Have you had a finding of, or are you currently facing a proceeding for professional misconduct, incompetence,
incapacity or a similar issue in another profession in Manitoba or another jurisdiction?
Yes  No 
Have you been convicted of, or indicted for, a criminal offence for which you have not been pardoned, or are you
currently undergoing a criminal investigation?
Yes  No 
If you answered YES to any of the above, COTM will contact you with information on how to proceed.
10. CONTINUING COMPETENCE PROGRAM (CCP) DECLARATION
Have you completed the PREP *2014-15 COTM registration year online quiz (Topic: Consent) and received
acknowledgement of completion?
Yes  No 
If Yes: Completion Date (mm/yy) _________________
If No: Reason Code: _________________
Have you completed a CCP Self-Assessment (SA) between June 1 2013 and the date of this renewal
application?
If Yes: Completion Date (mm/yy) _________________
Yes  No 
If No: Reason Code: _________________
Have you completed or updated a CCP Professional Development Plan between June 1, 2014 and the date of this renewal
application?
Yes  No 
If Yes: Completion Date (mm/yy) _________________
If No: Reason Code: _________________
Codes for “No”:
1= I have been on leave/nonpractising during *2014-15
3= I am registered and meeting CCP requirements in another province
2= I registered to practise for the first time in *2014-15
4= Other
If you answered OTHER for any of the NO answers, please
explain:_____________________________________________________________________________________________
___________________________________________________________________________________________________
FAILURE TO SUB MIT ALL DOCUMENTS FOR COTM RENEW AL BY MAY 31, 201 5** W ILL RESULT IN A LATE FEE
AL L CO T M M EM BER S M UST CO M PL ET E EI T HER S ECT IO N 1 1 O R 12
11. DECLARATION
I hereby declare that, to the best of my knowledge, the information provided on this application is true, correct and complete in every
respect. I agree to abide by The Occupational Therapists Act and Regulation and the By-laws and Code of Ethics of COTM and the
Essential Competencies of Practice for Occupational Therapists in Canada.
I understand that it is my responsibility to maintain professional liability insurance coverage for all relevant areas of practice.
SIGNATURE_______________________________________
DATE________________________________
12. RESIGNATION FROM COTM: Provide place and date of last employment as an OT.
Employer
Address of Employer including postal code
End Date
I wish to cancel my registration with the College of Occupational Therapists of Manitoba, and declare that I will not be practising O.T. in
Manitoba after May 31, 2015. I hereby declare that, to the best of my knowledge, the information provided on this application is true,
correct and complete in every respect. I understand reinstatement of registration is required prior to resuming O.T. practice in Manitoba.
SIGNATURE_______________________________________
DATE________________________________
13. COTM / MSOT NOMINATIONS: Please answer the following questions:
Would you consider serving on the Council of the College of Occupational Therapists of Manitoba? COTM is the regulatory organization
for O.T.’s in Manitoba.
 Currently serving
 Yes
 No
Would you consider serving on the Manitoba Society of Occupational Therapists Board or Committees? MSOT represents and advocates
on behalf of Manitoba’s occupational therapists.
 Currently serving
 Yes
 No
14. MSOT INFORMATION (to be completed by MSOT members only): Please answer the following questions:
Would you be willing and able to provide OT services in a language other than English?
Please specify language: ____________________
 Yes  No
MSOTRF (Manitoba Society of Occupational Therapists Research Fund)
Would you like to make a donation to the MSOTRF?  Yes $____________
(A cheque made payable to COTF (Canadian Occupational Therapy Foundation) can be forwarded with your renewal.)
Would you be willing to assist MSOTRF in reviewing grant applications?
 Yes  No
15. MEMBERSHIP FEES: Check the category(ies) of membership that apply and submit fee(s) accordingly.
College of Occupational Therapists of Manitoba
 Practising
$525.00
 Provisional
$525.00
 Non-Practising
$210.00
 Late Fee
$50.00
Manitoba Society of Occupational Therapists
 Full member
 Associate Member (Retired)
 Out of Province
 Installment Payment Option
$100.00
$37.50
$45.00
(Please see enclosed Information
sheet for further details)
COTM TOTAL
TOTAL ENCLOSED
$
MSOT TOTAL
$
$
Make cheque or money order for the total amount (including MSOT fees) payable to:
College of Occupational Therapists of Manitoba or COTM
(post-dated cheque or money order must be dated no later than June 1, 2015)
** Renewals will be accepted until 4:00 pm June 1, 2015 as a result of May 31, 2015 falling on a Sunday.
College of Occupational Therapists of Manitoba (COTM) & Manitoba Society of Occupational Therapists (MSOT)
7 – 120 Maryland Street, Winnipeg, Manitoba R3G 1L1
Phone: (204) 957.1214 Toll free: 1.866.957.1214 Fax: (204) 775.2340
Email: [email protected]; [email protected]
Web: www.cotm.ca; www.msot.mb.ca
FAILURE TO SUB MIT ALL DOCUMENTS FOR COTM RENEW AL BY MAY 31, 201 5** W ILL RESULT IN A LATE FEE