Residency Program Inquiry and Contacts Survey Question Title * 1. Please enter your contact information Name: Company: State: Email Address: Phone Number: Name Institution State Job Title Email Phone Question Title * 2. Are you the primary decision maker regarding a Residency Program at this site? If not, please provide additional information about who is. Yes No Other (please specify) Question Title * 3. What is the area of practice for which you would like to provide a Residency? Question Title * 4. To which AOTA Certification(s) does this Residency best connect? Information about AOTA Certification programs can be found at www.aota.org/certification. Board Certification- Gerontology Board Certification- Mental Health Board Certification- Pediatrics Board Certification- Physical Rehabilitation Specialty Certification- Driving and Community Mobility Specialty Certification- Environmental Modification specialty Certification- Feeding, Eating, Swallowing\ Specialty Certification- Low Vision Specialty Certification- School System Question Title * 5. At what stage in the planning and development for an OT Residency Program is your organization? Just starting to explore the possibility Initial discussions have occurred within the setting Initial approval to proceed with a Residency Program has been granted We currently have an OT Residency Program in place Question Title * 6. Do you have a Residency Program at your setting for a discipline other than OT? If so, what disciplines? Yes No Other (please specify) Done