Certified Member Facility Renewal Application

OMA Certified Facility Renewal Application

You must be regularly offering OMA in order to renew your membership.

*= required field

Today's Date*

MM

DD

YYYY

Have you had OMA sessions at your facility in the last 12 months?*

Yes
No

You must be offering OMA regularly to apply for a Certified Member Facility. Please re-apply when you have re-activated your OMA program.

Your Contact Information

Name*

First Last

Email*

Job Title*

Phone*

Fax

Your Organization's Information

Company Name*

Company Website*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of Residents*

Please enter a number from 1 to 10000.

Not-for-Profit Organization*

Yes
No

Are/Were You a QIP Recipient?*

Yes
No

OMA Information

Name(s) of Trained OMA Facilitator(s) currently employed at your organization:*

Location of OMA Facilitator Training:*

Date of OMA Facilitator Training Completion*

MM

DD

YYYY

Is This a Certified Facility Membership renewal?*

Yes
No

How often do you conduct the OMA program?*

Once a month
Once a week
Twice a week
More than twice a week

Which group primarily serves as your volunteers?*

How many pairs of residents and volunteers did you serve in the last 12 months?*

How did you train your OMA volunteers?*

We provided verbal instruction to the volunteers.
We used the online videos provided for training.
We used the online videos and supplemental material.

Supporting Video/Photos

Please click the Submit button below to complete this form.

Once this form has been completed you will be taken to a page with instructions for submitting your 5-10 min. video(s) and photos. Video submission is required. Photos may be sent in addition to the video and may be sent separately or inserted into the video clips. You may upload up to 10 separate clips (each clip less than 2 min. long). Your submission should show examples of all four components below:

OMA art session in action (pairs working together)
6-10 images of OMA art projects created by different people with dementia on different days. These images should show a variety of art projects completed.
Art show reception
Interviews with 2-3 volunteers.

Photos/videos submitted will be used for reviewing purposes only by Scripps OMA staff. They will not be made public. Please remove nametags and other possible identifiers prior to recording videos. This will ensure that there is no way for Scripps staff members to identify the OMA artist on the video; therefore removing any possibility of HIPAA violation. For more details on HIPAA, please click here.

Submit Your Form

Please click the Submit button below to complete this form.

Submit Your Form

Please click the Submit button below to complete this form.