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Section II: Employer Certification of Supervision

Instructions to the Employer and Supervisor:

1. By completing the sections below you are certifying that the permit applicant named in Section I will be employed under the supervision of a New

York State licensed and currently registered occupational therapist or physician.

2. A limited permit shall expire one year from the date it was issued.

3. The limited permit does not authorize the treatment of patients in a home care service of any hospital, clinic or agency or in a private

practice.

Print full name of employer: __________________________________________________________________________________________________

Street address: ____________________________________________________________________________________________________________

City: ___________________________________________________________________ State: _______________ Zip code: ____________________

Telephone: _________________________________ Fax: ________________________________ E-mail ___________________________________

Applicant Practice Site Information

Site: _____________________________________________________________________________________________________________________

Address: _________________________________________________________________________________________________________________

The above facility is a: (check one)

Public hospital

Public health agency

Voluntary hospital

Licensed proprietary hospital

Licensed nursing home

Recognized public or non-public school setting

Incorporated hospital or clinic

Site: _____________________________________________________________________________________________________________________

Address: _________________________________________________________________________________________________________________

The above facility is a: (check one)

Public hospital

Public health agency

Voluntary hospital

Licensed proprietary hospital

Licensed nursing home

Recognized public or non-public school setting

Incorporated hospital or clinic

Attestation

In accordance with the instructions above, I declare that the statements made in Section II are true, complete and correct. Any false or

misleading information in, or in connection with, this certification may be cause for loss of licensure and may result in criminal

prosecution.

Supervisor’s name: _________________________________________________________________________________________________________

Are you employed at the same place of employment as the applicant?

Yes

If yes, how many hours per week are you employed there? ____________________________

Supervisor's signature: _________________________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Credentials:

Occupational Therapist

Physician

New York State license number: _____________________________________

Address: _________________________________________________________________________________________________________________

Telephone: ( __________ ) ____________________ Fax: ( __________ ) ____________________

E-mail __________________________________________________________________________

New York State Education Department, Office of the Professions, Division of Professional Licensing Services,

RETURN DIRECTLY

P.O. Box 22063, Albany, NY 12201

TO:

Occupational Therapy Form 5, Page 2 of 2, Rev. 8/15

Occupational Therapy Form 5 - Application For A Limited Permit - New York The State Education Department Page 2

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