Quality Assurance Request Form

Taking part in the QA program gives occupational therapists a chance to reflect on their practice. It helps them to focus on where they need to learn more to ensure they can provide safe, effective, ethical care.

However, if you require an extension or would like to request an exemption or accommodations, you can submit a request to the Quality Assurance program.

To request an extension, exemption, or accommodation, please submit this form as soon as possible.

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you your specify

Registrant Name *

First

Last

Registrant Number

Email *

Phone

This request applies to

• Annual Learning Plan
• Annual eLearning Module
• Competency Assessment*

*If you are not able to participate in the Competency Assessment, you will be automatically included in the next selection group.

Are you requesting

• Extension
• Exemption
• Accommodation*

*You may be asked to provide supporting documentation.

Requested extension

• 30 days
• 60 days
• Other

Please specify

Reason for your request

• Extenuating circumstances
• Not currently practicing/working
• On parental leave
• On leave of absence
• Other

Not currently practicing/working until:

On parental leave until:

On leave of absence until:

Please specify

In this section, you can provide details about the reason for your request

Submit

If you are having any issues with the form, please contact us at qaprogram@coto.org.