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submitting Professional Experience as part of the (a) New Applicant-Professional Eligibility Application process, or (b) CTRS Recertification audit process.  \nAGENCY INFORMATION  \nAgency Name:  \n\n| Mailing Address: |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| City: | State/Province: |  | Postal Code: | Country: |\n| Phone: |  | Email: |  |  |\n| APPLICANT RELEASE AND AUTHORIZATION\u003Cbr>Based on applicant request for employer to complete this form, permission is hereby granted to furnish employment information as part of the certification requirements for the National Council for Therapeutic Recreation Certification (NCTRC) .\u003Cbr>Name (first, middle/maiden, last): |  |  |  |  |\n| Employment Start Date: |  | Employment End/Present Date: |  |  |\n| Check one box related to the application process requiring verification of employment hours; specify job title/role for the identified dates:\u003Cbr>Within the job title/role of   , I have completed a minimum of 5000 hours paid work experience that uses the therapeutic recreation process (NEW APPLICANT-PROFESSIONAL ELIGIBILITY APPLICATION). |  |  |  |  |\n| Within the job title/role of   , I have completed a minimum of 1500 hours paid work experience that uses the therapeutic recreation process (NEW APPLICANT-PROFESSIONAL ELIGIBILITY APPLICATION). |  |  |  |  |\n| Within the job title/role of   , I have completed 480 hours paid or volunteer work experience in therapeutic recreation services within the five-year certification cycle as required (CTRS® RECERTIFICATION AUDIT PROCESS). |  |  |  |  |\n\nThis section of the form must be completed by Human Resource, Personnel Authority or Supervisor/Manager.  \nEMPLOYER VERIFICATION OF WORK EXPERIENCE IN THERAPEUTIC RECREATION/ RECREATION THERAPY  \nTo the best of your knowledge and according to your records, during the dates of employment listed above, was this individual:  \n1. Employed for the above dates, job title and therapeutic recreation duties? If NO, please provide correct dates of employment and job title in the comment box below.  \nYes No  \n2. Subject to an investigation or disciplinary action, suspension or termination by your organization or other health care organization that directly related to the provision of therapeutic recreation/ recreation therapy services and/or public health and safety?  \n3. Subject to an investigation or disciplinary action by a governmental entity or regulatory or licensing agency or authority that directly related to the provision of therapeutic recreation/ recreation therapy services and/or public health and safety?  \n4. Investigated, charged or convicted of any felony or misdemeanor directly relating to the provision of therapeutic recreation/recreation therapy services and/or public health and safety?  \nYes  \nYes  \nYes  \nNo  \nNo  \nNo  \nPlease describe any YES responses for questions 2 through 4 below and include any documentation you believe may be of assistance to NCTRC in reviewing this applicant.  \n\n| Human Resource, Personnel Authority or Supervisor/Manager Signature | Date |\n| --- | --- |\n\nPrinted Name Job Title  \nNational Council for Therapeutic Recreation Certification®  \nProtecting and Promoting Since 1981  \n845 639 1439  \n[nctrc.org](nctrc.org)  \n©2025 National Council for Therapeutic Recreation Certification® All rights reserved.  \nNC.1044.1","cbCaiujLWZcUBekR","https://ap.wps.com/l/cbCaiujLWZcUBekR","pdf",236936,"English","# Overview\n# Eligibility\n# Agency Information\n# Applicant Release and Authorization\n# Employer Verification of Work Experience in Therapeutic Recreation/Recreation Therapy\n## Employer Questions 1-4\n# Signature and Date","[{\"question\":\"该Employment Verification Form适用于哪些申请流程？\",\"answer\":\"适用于新申请专业资格资格申请流程以及CTRS再认证审计流程。提交专业经验时需按NCTRC现行认证标准完成。\"},{\"question\":\"申请人需在表格中选择哪种小时数要求？\",\"answer\":\"表格提供三种选择：新申请专业资格资格申请要求至少5000小时；另一项要求至少1500小时；再认证审计流程要求在五年认证周期内完成480小时有偿或志愿的治疗性娱乐服务相关工作。\"},{\"question\":\"雇主需要由谁填写并核验哪些信息？\",\"answer\":\"需由人力资源、人员负责人或主管/经理完成。雇主需确认被核验者在给定日期与岗位职责下是否受雇提供治疗性娱乐/娱乐治疗服务，并回答是否存在调查、纪律处分、停职/解雇及相关刑事指控。\"}]","Employment Verification Form - NCTRC | PDF"]