Application for Initial Credentialingand

APPLICATION FOR INITIAL CREDENTIALINGAND

RE-CREDENTIALING OF RESIDENCY & FELLOWSHIP PROGRAMS

Application Residency/Fellowship Credentialing 2013 Edition

APPLICATION FOR RESIDENCY/FELLOWSHIP PROGRAM CREDENTIALING

INTRODUCTION

Thank you for your interest in credentialing your developing or existing residency or fellowship program. Congratulations on your commitment to excellence in physical therapy education.

This document should be reviewed along with the “Evaluative Criteria for Credentialing Residency/Fellowship Programs for Physical Therapists”. This document can be downloaded from the APTA website at

Additionally, APTA’s American Board of Physical Therapy Residency and Fellowship Education(ABPTRFE) has compiled the Application Resource Manual, also available on the Residency/Fellowship website, to serve as a guide as you prepare your documents for credentialing. These real examples were provided by APTA credentialed programs and are not intended to be prescriptive, as every program is unique and its individuality should be reflected in the application.

Programs may seek assistance for program development from either the APTA Residency/Fellowship staff or the Program Services Council of ABPTRFE. If you wish to request assistance, please contact the Department of Postprofessional Certification and Credentialingat r 703-706-3152. Please do not hesitate to contact us as you develop your program and prepare your application for credentialing.

Please retain this application information for reference throughout the application process and future credentialing period. Replace with most current edition, as they are made available.

2013 Edition

Residency and Fellowship Program Credentialing

Application Instructions

The application for credentialing is based on the “Evaluative Criteria for Credentialing Residency/Fellowship Programs for Physical Therapists”.

For each Evidence, provide a brief description of how the Program meets the evaluative criteria and the documentation or materials as requested in the “Evaluative Criteria for Credentialing Residency/Fellowship Programs for Physical Therapists”.

Please note that the Program must have current residents and/or fellows during the application period.

Application fees are determined by the number of residents/fellows enrolled in the Program at the time of application. The credentialing process must be completed within one year from the date that the application is received at APTA. Programs that fail to complete the credentialing process within that year will be required to pay an additional application fee equal to one half of the original application fee.

1. Compilation of Application

_____The materials must be provided in hard copy in a three-ring binder. Please submitfive (5)copies of the complete application. Materials should be collated and may be printed on front and back of the paper to limit weight. Please type your Program’s responses directly into the application. You may cut and paste additional materials into the appropriate Evidence numbers.

2. Materials to be Included

An application must include the materials as listed in the order below. Please compile the materials in the following order:

_____A.Signature Page – Each person whose signature is required on the signature page is to review the compiled report prior to signing off on the application.

_____B.Applicant Information for Residency or Fellowship Program Credential – Contact information is generated from this form, making it essential that the form be complete and accurate. It is the Program’s responsibility to notify APTA staff of any changes on this form.

_____C.Residency or Fellowship Program Agreement –Signatures of the Program director or coordinator and the umbrella organization’s administrator are required with submission of the application.

_____D. Preface– A general historical overview of the Program should be included. This overview should serve as the introduction to the application. If your Program is new, describe the factors that led to the initiation of the Program. Please limit the Preface to two (2) pages.

_____ E. Description of compliance –Provide a brief descriptive response for each “Evidence” section within the body of the application. Responses on required forms are to be typed or legibly hand-printed in black ink, which permits legible photocopying. The exceptions to this are certain items, such as recruitment brochures, etc., which can be legible photocopies of the original materials published by the umbrella organization or Program. Where photocopies of materials published by the umbrella organization or Program are supplied as part of the evidence document, they should clearly indicate the name or title of the source and the date of publication. Please insert these additional materials directly into the application following the respective Evidence.

_____ F. Application Fee – Application fees are determined by the number of residents/fellows enrolled in the Program at the time of application. Please mail the non-refundable application fee at the time that the application is submitted to prevent processing delays. All fees must be received before the application will be reviewed. Please download the current “Payment Form” located on the APTA website at and include this payment form with your Program’s application fee.

3. Submission of the Application and Fee

_____The application fee and a total of five (5) copies of the compiled application in 3-ring binders should be mailed to APTA, Department of Residency/Fellowship, 1111 North Fairfax Street, Alexandria, VA22314-1488. Please include the “Payment Form” located on the APTA website with the application fee.

Please direct questions regarding the application process to the APTA Residency/Fellowship staff at 703.706.3152 or via e-mail at .

APPLICATION FOR CREDENTIALING OF A RESIDENCY OR FELLOWSHIP

PROGRAM FOR PHYSICAL THERAPISTS

PROGRAM NAME:

Check one:RESIDENCY FELLOWSHIP

NAME OF UMBRELLA ORGANIZATION:

MAILING ADDRESS:

PLEASE INDICATE WHICH EDITION OF THE APPLICATION WAS USED:

*Please note that starting January 1, the version of the application that must be submitted is the one for that respective year. If the previous year’s application is utilized after January 1, the Program will be notified that they must revise and resubmit the application using the current year’s application. This may result in a delay of the credentialing process with an additional fee being charged for those Programs that exceed the one year application timeline.

The Program named above submits the following information in fulfillment of the APTA requirements for credentialing of a physical therapy residency or fellowship program.

The information submitted in this application is a true and accurate description of the umbrella organization and the residency or fellowship program with respect to the information requested.

PROGRAM DIRECTOR/COORDINATORORGANIZATION ADMINISTRATOR

TITLETITLE

SIGNATURE SIGNATURE

DATE DATE

INSTRUCTIONS: Complete and attach this sheet, or a photocopy of this sheet, to the front of each of five (5) copies of the application materials being submitted. Submit all materials to:

Department of Residency/Fellowship

American Physical Therapy Association

1111 North Fairfax Street

Alexandria, VA 22314-1488

AMERICAN PHYSICAL THERAPY ASSOCIATION

Applicant Information for Residency or Fellowship Program Credentialing

Please type or print.Date Completed:

NAME OF PROGRAM
TYPE OF PROGRAM: RESIDENCY FELLOWSHIP
SPONSORING UMBRELLA ORGANIZATION
PROGRAM ADDRESS / LINE 1
LINE 2
CITY / STATE / ZIP CODE
TELEPHONE / FAX / WEBSITE (if available)
PROGRAM DIRECTOR/COORDINATOR
NAME (last) / (first) / (middle initial)
CREDENTIALS (i.e. PT, DPT, OCS, etc.) / TELEPHONE / FAX / E-MAIL
PRIMARY CONTACT (if different from Program Director/Coordinator)
NAME (last) / (first) / (middle initial)
CREDENTIALS (i.e. PT, DPT, OCS, etc.) / TELEPHONE / FAX / E-MAIL
PROGRAM INFORMATION
TYPE OF PROGRAM
RESIDENCY
FELLOWSHIP / YEAR PROGRAM
STARTED / LENGTH OF PROGRAM
months
hours / CURRENT # RESIDENTS/FELLOWS-IN-TRAINING / RESIDENT/FELLOW TUITION/FEE?
NO YES AMOUNT$
*please include fees associated with books, coursework, insurance, etc. (if applicable)
MAXIMUM NUMBER OF RESIDENTS/FELLOWS-IN-TRAINING PROGRAM WILL ENROLL
FULL-TIME PART-TIME
IS THIS PROGRAM CONSIDERED A MULTI-SITE PROGRAM PER THE DEFINITION OUTLINED BY ABPTRFE? No Yes
IF YES AND THIS PROGRAM IS A RESIDENCY PROGRAM, IS THERE AT LEAST ONE ABPTS CERTIFIED SPECIALIST AT EACH FACILITY? No Yes
TYPE OF RESIDENCY/FELLOWSHIP CONCENTRATION / COMPENSATION TO RESIDENT/FELLOW?
NO YES AMOUNT$ per year/hour
Please indicate what the percent of this salary is compared to a regular employee at your facility (ex: 100%, 75%, 60% of a regular employee’s salary):
How many hours per week does the resident/fellow spend in clinical practice?
BENEFITS PROVIDED TO RESIDENT/FELLOW
DOES PROGRAM RECEIVE NON-TUITION INCOME?
No Yes
Sponsor: Amount: $ / FELLOW SCHOLARSHIP FUNDED BY OUTSIDE AGENCIES?
No Yes
Sponsor: Amount: $ / IS YOUR PROGRAM ASSOCIATED WITH EARNING A DEGREE?
No Yes Degree earned:
PROGRAM DATES FIXED ROLLING
STARTING (month/year) ENDING (month/year) / APPLICATION DEADLINE FIXED ROLLING DATES:
APPLICANT INTERVIEW: Not required Required of each applicant

AMERICAN PHYSICAL THERAPY ASSOCIATION (APTA)

Residency/Fellowship Program Agreement

In consideration of APTA’s review of the application you have submitted for approval of your Program as a Credentialed Residency or Fellowship Program, you hereby agree as follows:

1.You will furnish accurate and complete information to APTA, and will work cooperatively with it in connection with its review of your application and its monitoring of compliance with your obligations.

2.You will fund direct expenses of travel, lodging, and meals for a team of two persons, designated by APTA, to visit facilities housing the Program for the purpose of gathering further information about your Program. If a second site visit is required, the Program will fund one person.

If APTA credentials you, you further agree that:

3.You will report to APTA in writing, within thirty (30) days, any major organizational or programming change that may affect the operation of your Program.

4.In the course of promoting your Program, you will provide complete and accurate information about your Program, services, and fees.

5.Your Program will remain in substantial compliance with the Evaluative Criteria for Credentialing of Clinical Residency and Fellowship Programs for Physical Therapists.

6.You will comply with APTA’s policies and positions. You will not place any resident/fellow in a clinical education experience where the clinic is in a referral for profit situation, that is, one in which a referring physician (medical doctor, doctor of osteopathy, podiatrist, dentist, or chiropractor) derives a financial benefit from the physical therapy services provided to the person who is referred. The situations to which this restriction applies include those in which: (a) the physician has an ownership interest in a physical therapy practice to which he or she refers, (b) the physician or the physician’s practice employs or contracts with physical therapists to provide physical therapy services within the physician practice, or (c) the physician’s income or bonus is directly or indirectly tied to the revenues of the physical therapy service to which he or she refers patients.

7.You will file an annual report, furnish requested information, and pay fees on a timely basis. (See the American Board of Physical Therapy Residency & Fellowship Education Credentialing Handbook for further information.)

8.You will conduct your operations and Program in an ethical manner.

9.You will not publicize, claim, or imply that you are (or were) a Credentialed Residency or Fellowship Program, except as specifically permitted by APTA in the American Board of Physical Therapy Residency & Fellowship Education Credentialing Handbook.

10.You will not print or otherwise use the designated logo, except as specifically permitted by APTA in the American Board of Physical Therapy Residency & Fellowship Education Credentialing Handbook.

11.If APTA, in good faith, institutes any legal action against you on account of any violation of this Agreement, you will indemnify APTA for all its expenses of preparing for, instituting, prosecuting, and/or settling such an action.

12.You agree that noncompliance with this Agreement constitutes grounds for withdrawal of credentialing.

(Name of Program) hereby agrees with all foregoing terms and conditions.

Program Director/Coordinator Name & Title (Print/Type)Organization Administrator Name & Title (Print/Type)

______

Program Director/Coordinator SignatureDateOrganization Administrator Signature Date

Name of Residency/Fellowship Program:

Address:

City/State/Zip:

PREFACE

Please provide a brief historical overview of your Program. This overview should serve as an introduction to the application. If your Program is new, please describe the factors that led to initiation of the Program. Please limit the Preface to two (2) pages.

1.0ORGANIZATION

Residency or Fellowship Umbrella Organization

Evidence 1.1.1Provide the statement of mission and goals of the umbrella organization that most directly influences the Program.

Evidence 1.1.2Describe the umbrella organization’s ongoing methods used to evaluate the effectiveness of the umbrella organization’s performance. Include evidence of any external agency accreditations (e.g., JCAHO, CARF, Medicare provider or provider network standards, CAPTE or another educational accreditation organization if applicable).

Residency or Fellowship Program

Evidence 1.2.1.A Provide the Program’s mission statement, goals and objectives. Multi-site Programs must include at least one goal and corresponding objectives addressing consistency of program delivery in all settings.

The goals of the Program are to:

1. Goal:

Objectives:

a.

b.

c.

*add additional goals/objectives as needed

Evidence 1.2.1.B Describe how the Program’s mission statement, goals, and objectives are consistent with one another.

Evidence 1.2.1.C Describe how the Program’s mission, goals, and objectives are consistent with the mission of the umbrella organization.

Evidence 1.2.1.D Provide the resident/fellow-in-training goals with corresponding objectives.

The goals of the resident/fellow-in-training are to:

1. 1. Goal:

Objectives:

a.

b.

c.

*add additional goals/objectives as needed

Program Policies & Procedures

Evidence 1.2.2Provide the Program’s policies and procedures for the resident/fellow-in-training handbook and Program and/or umbrella organization’s policy and procedures manual(s) for all items listed in 1.2.2 in the American Board of Physical Therapy Residency & Fellowship Education “Evaluative Criteria for Credentialing Residency/Fellowship Programs for Physical Therapists”. Please do not send the organization’s entire policy and procedures manual.

Resident/Fellow Policies and Procedures

Evidence 1.2.3.1Provide the recruitment materials (not a link to the Program’s website)

Evidence 1.2.3.2 Provide a copy of a blank contract or agreement or letter of appointment.

Evidence 1.2.3.3 Utilize the Form below to provide the name, physical therapy license number and state, and status (active or inactive) for all currently enrolled residents or fellows-in-training.Add additional rows as needed.

RESIDENT/FELLOW-IN-TRAINING NAME

/ LICENSE # (with state) / START DATE
(MONTH/YEAR) / STATUS
Active Full Time
Active Part-Time
Inactive
Active Full Time
Active Part-Time
Inactive
Active Full Time
Active Part-Time
Inactive
Active Full Time
Active Part-Time
Inactive
Active Full Time
Active Part-Time
Inactive
Active Full Time
Active Part-Time
Inactive
Active Full Time
Active Part-Time
Inactive
Active Full Time
Active Part-Time
Inactive

Application Residency/Fellowship Credentialing 1 2013 Edition

2.0RESOURCES

Patient/Client Population

Evidence 2.1.1.A Using the Form below, summarize the number of patients/clients (not number of visits) by diagnostic categories evaluated, treated, and/or managed by the resident/fellow-in-training over the last year as part of the residency or fellowship program. Do not provide data on patient/clients seen by all staff in the clinic. Copy this form as needed. New Programs provide data since the start date of the resident/fellow-in-training. Categorize the patient/client population in a manner that clearly captures the intent of the DSP/DASP/practice analysis upon which the Program is based (categorize by diagnosis, impairment, body region, and/or practice location, as needed). For orthopaedic residency, sports residency, and orthopaedic manual physical therapy fellowship programs, please use the Form provided. This chart should also provide a summary of the percentage of the total patient/client population represented in this category.

Application Residency/Fellowship Credentialing 1 2013 Edition

Description of Patients by Diagnostic Group/Impairment Category

*For orthopaedic residency, sports residency, and orthopaedic manual physical therapy fellowship programs, please use the appropriate form as labeled

Name of Resident/Fellow

(Include a separate form for EACH resident/fellow currently enrolled in the Program)

DIAGNOSTIC GROUP OR CATEGORY

/ NUMBER OF PATIENTS/CLIENTS TREATED BY RESIDENT OR FELLOW AS PART OF THE PROGRAM / % OF TOTAL PATIENTS/
CLIENTS TREATED BY RESIDENT OR FELLOW

* Be as descriptive as possible in defining Diagnostic Group/Category. See examples in Application Resource Manual.

Application Residency/Fellowship Credentialing 1 2013 Edition

ORTHOPAEDIC RESIDENCY PROGRAMS, USE THIS FORM

Name of Resident

(Include a separate form for EACH resident currently enrolled in the Program)

DIAGNOSTIC GROUP OR CATEGORY / NUMBER OF PATIENTS/CLIENTS TREATED BY THE RESIDENT AS PART OF THE PROGRAM / % OF TOTAL PATIENTS/
CLIENTS TREATED BY THE RESIDENT / THE % INDICATED BELOW ARE PER THE DSP GUIDELINES. PROGRAMS SHOULD BE TARGETING
Cranial/Mandibular / 5%
Cervical Spine / 15%
Thoracic Spine/Ribs / 5%
Lumbar Spine / 20%
Pelvic Girdle/Sacroiliac/Coccyx/
Abdomen / 5%
Shoulder/Shoulder Girdle / 15%
Arm/Elbow / 5%
Wrist/Hand / 5%
Hip / 5%
Thigh/Knee / 10%
Leg/Ankle/Foot / 10%
Total / 100%

Application Residency/Fellowship Credentialing 1 2013 Edition

ORTHOPAEDIC MANUAL PHYSICAL THERAPY FELLOWSHIP PROGRAMS, USE THIS FORM

Name of Fellow-in-training

(Include a separate form for EACH fellow-in-training currently enrolled in the Program)

DIAGNOSTIC GROUP OR CATEGORY / NUMBER OF PATIENTS/CLIENTS TREATED BY THE FELLOW-IN-TRAINING AS PART OF THE PROGRAM / % OF TOTAL PATIENTS/
CLIENTS TREATED THE FELLOW-IN-TRAINING
Cranial/Mandibular
Cervical Spine
Thoracic Spine/Ribs
Lumbar Spine
Pelvic Girdle/Sacroiliac/Coccyx/
Abdomen
Shoulder/Shoulder Girdle
Arm/Elbow
Wrist/Hand
Hip
Thigh/Knee
Leg/Ankle/Foot
Total

Application Residency/Fellowship Credentialing 1 2013 Edition