The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability,
or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
Authority: 1978 PA 368
Section of Form to be Completed by Applicant:
Applicant’s First Name
Middle Name
Last Name
Telephone Number (with area code)
MI License Number
Date of Birth (MM/DD/YYYY)
Remainder of Form to be Completed by Supervisor:
Name of Agency
Address of Agency
Zip Code
I certify the applicant named above practiced occupational therapy under my supervision from _____________________________ to
for a total of _________________ hours.
I also certify I have received training in the function of supervision pursuant to Administrative Rule 338.1228 and 338.1237, as cited
below, and conducted supervision pursuant to applicable statutes and administrative rules. I was available on a regularly scheduled
basis to review the practice of the applicant, to provide consultation, to review records, to further educate the applicant and there was
continuous availability of direct communication in person or by radio, telephone or telecommunication.
Rule R 338.1228 and R 338.1237:
(1) The supervised practice experience required for relicensure under R338.1227 and R338.1236 shall comply with all of the following:
(a) The supervised practice experience shall be obtained under the supervision of an Occupational Therapist licensed in this state having not less
than 3 years clinical experience and no past or pending disciplinary actions.
(b) The supervising Occupational Therapist shall provide the board with verification of the applicant’s completion of the supervised practice experience
on a form provided by the department.
(2) The supervised practice shall consist of, at a minimum, professional and clinical instruction in ALL of the following areas:
(a) referral process
(b) screening process
(c) evaluations
(d) intervention plans
(e) intervention strategies
(f) discontinuation; referral for other services
(3) Only experience obtained in an approved supervised practice situation by an individual who holds a limited license shall count toward the experience
____________________________________________________ ____________________________________________
Signature of Supervisor Date
Print or Type Name of Supervisor
______________________________________________ ______________________________________________
Michigan Permanent OT ID Number, if applicable State licensed in and Type of License
, if not Michigan