GERIATRICS
PROFESSIONALDEVELOPMENTPORTFOLIO
Blank Forms
ApplicationDeadline:October 31st,2018
Checklist forRecertification
Pleaseverifythatthefollowinginformationiscompletedbeforeyousubmityourapplication:
VerificationofPhysicalTherapyLicense(Ifyourstatedoesnothavelicenseverificationavailableviathe Internet,youmustrequestthatlicenseverificationfromyourstateboardanduploadascannedcopyto the Name section of the onlineapplication)
Completion of your online recertificationapplication.
All Professional Development Activities forms are typewritten and completed infull
(no CV’s or resumes accepted). Thisincludes:
- Professional Development Activities SummaryForm
- Professional Development Activities Total Points SummaryChart
*Only use the forms for which you will be submitting evidence to support activity in a certainarea.*
SubmitallsupportingdocumentationfortheProfessionalDevelopmentActivitieslistedinthe following forms.
Complete your recertification paymentonline:
$650 APTAMembers
$910 Non-APTAMembers
Did you print a copy of your application for yourrecords?
SubmityourProfessionalDevelopmentPortfolio(PDP)formsonlineat.Ifyouhaveany questions or concerns with how to complete this step please contactus.
The Recertification Application must be submitted online for recertificationconsideration.
If you have any questions or concerns please contact usvia:Phone: 1-800/999-2782, ext.3390
Direct Line:703-706-3390
Email:
1
SAMPLE – Professional Development Portfolio Summary -Geriatrics
Instructions- Professional Development Activities (PDA) / Description of Specialty Practice (DSP) – identifythe category for the activity and enter the point credit according to the ABPTS guidelines.Numbers correspondtoABPTSguidelinenumbersontheApprovedProfessionalDevelopmentActivitiessheet.
- Candidates are required to obtain PDP activity points in at least 3 professionaldevelopmentactivities. A candidate must have earned a minimum of 1 point in an activity to be countedtoward thisrequirement.
- Total points required =35
- DSP category Elements of Practice = 4 points minimumrequired
- DSP category Patient Care = No minimum beyond minimum eligibility requirement of 2000hours
- DSP category Knowledge Base = 4 points minimumrequired
DSPCategory / Professional DevelopmentActivities / Your Points PerPDA Category / Total Points PerDSP Category
Elementsof Practice (A)
(4points minimum) / 4.Teaching acourse / 6.3 / 25
5. ProfessionalPresentation / 1.1
6. ProfessionalWriting / 6
7. ProfessionalServices / 11.6
PatientCare(B) / 1. Direct PatientCare
(20 pointsmax) / 20 / 20
8. Clinical Supervision &Consultation / 0
9b. Contributions to PTOutcomes Database / 0
KnowledgeBase(C)
(4points minimum) / 2. Participating in CECourse / 2.3 / 5.3
3. Completion of acollege/university course / 3.0
9a. Contribution to ResearchProject / 0
(An excess of 60 points will result in delayedprocessing/review) TOTAL / 50.3
2
Approved Professional DevelopmentActivities
Activity / PointValue / InformationNeeded/ supportingdocumentation / Example- Direct Patient Care hours in specialtyarea (beyond minimum eligibility requirement) 0.1(per10hours)
1000hrs
2.Participating in a continuing educationcoursewith specific goals and objectives relatedtospecialtypractice.
1pt per 10 contacthours / Date, Title, Location, and Description:ifneeded, # of CEU orcontacthours. Attach specificcoursedescriptions for each CEcourseattended (i.e. courseoutline,announcement, or objectivesorthe certification ofcompletion.)
3. Satisfactory completion of acollege/university course for credit or audit related to specialtyarea 1 pt per credithour / Date, Title, Location, and Description:ifneeded, # of credit hoursmustinclude a copy of theirtranscripts Attach official orunofficialtranscripts. / University Course – BiologyofAging. DepartmentofPreventiveMedicineUniversity of WI,Madison,Spring 2012 3 creditcourse
4.Teaching a continuing education courseorcollege/university course related tospecialty area. (Point value decreases for the secondtimea course is taught. Credit is given only for thefirsttwo times a course istaught.)
a.First Time = 0.2 (per contacthour)
b.Second Time = 0.1 (per contacthour) / Title /Description, if needed,Date:Semester/year, School, Location,# Hours taught, # of lab hoursifappropriate, 1st or secondtime,number of CEU or contacthours.Attach specificcourse descriptions for eachcontinuing education course attended(i.e.course outline, announcement,orobjectives / Taught entry-levelPTGeriatricsunit
Spring Semester2008,University ofWisconsin,Madison
11 hours (secondtime)
5.Professional Presentations in specialtyarea.(Creditisgivenonlyforfirsttimeapresentationismade.)
a. Platform or poster presentation ata professionalmeeting1 ptperpresentation) / Platform orPoster
Date/Title /Description ifneeded,Sponsor,Location
Attach:
Flyer, Letter from Sponsor,orProgram, etc., abstractofplatform/posterpresentation / Poster presentation attheGerontological SocietyofAmerica entitled“Are FunctionallyDependentElders AppropriatelyTargeted for In-home PhysicalTherapyafter HospitalDischargeOctober2009,
Los Angeles,CA
b. Invited speaker to a group, classes, orportionsof courses (includingin-services)
0.1 pt perhour / Platform orPoster
Date/Title /Description ifneeded,Sponsor,Location
Attach:
Flyer, Letter fromSponsor,Program,etc. / Presentation ontheFunctional ConsequencesofHospitalization in theElderly Sponsored by theUniversity ofWisconsin
February 26, 2008 (onehour)
c. Presentation to non-professional communityorclient-based groups on topic specifictospecialtyarea
0.1 pt perhour / Platform or Poster,Date/Title
/Description if needed,Sponsor,Location
Attach:
Flyer, Letter fromSponsor,Program,etc.
3
6.Professional Writing - Can include editor, author, or co-author ofpublicationsAuthor
a. book chapter – multiply number of chaptersby2 pointsifyou wrote more than one chapteroran entirebook
2.0 perchapter / Title, Publication,date
Can include editor, author, orco- author ofpublications
b.peerreviewedjournalarticle3.0perarticle / Title, Publication,date
c.non-peer reviewedpublication0.5 perarticle / Title, Publication,date
d.reviews orcommentaries0.5perreview orcommentary
e.case study or case report(peer-reviewed journal)
2.0 percase
f.grant proposal, primary investigator orco- investigator
2.0 per internalproposal
3.0 per externalproposal / Date, description,# ofhours Supported by a letter fromtheprimaryinvestigator
Editor
g. book editor – multiply number of chapters by 0.5ifyoueditedmore than one chapter or anentirebook
0.5 perchapter / Name of Book, title ofchapters
h.peer reviewed journaleditor1.5 peryear
i.editorial boardmember1.0 peryear
j.non-peer reviewed publication 0.75 peryear
k.manuscriptreviewer0.5perreview / Manuscript Reviewer forPhysical Therapy Title, numberofmanuscripts
7.Professional services
a. Committee Participation peryear
Note: Can be at local, state, or nationallevel
1.0 per year asmember
2.0 per year as chair, item review coordinatorand MOSCrepresentative / Committee name, datesofservice, member orchair
(eg, specialty council,sectionofficer, special interestgroup,organization outside APTArelated to specialtyarea) / Chair, GeriatricSpecialty Council of theAmericanBoard of PhysicalTherapySpecialties,2004-2005
b. Subject Matter Expert,Consultant
Note: Can be at local, state, or nationallevel
0.1 (perhour) / Date,description,number ofhours
eg, expert witness, grantreviewer,insurance reviewer, liaisonorconsultant toprofessionalassociation, service,oreducational program,certificationexam development,includingitemediting.
4
c. Item writing for certificationexam 1pt per 3 accepteditems / Dates of service, number ofitems submitted / Submitted 4 items toGeriatricSACE committee2005.d. Administration activities related topatientcare/services
0.5 (peryear) / (eg, development of policiesand procedures; marketing andpublicrelations; orientationand mentoring of new staff,and supervision of physical therapistsina managementrole
8. Clinical Supervision of students/peersorconsultation with peers in a health careprofession(The same hours cannot be counted forbothclinical supervision and direct patientcare.)
0.1 (per 10hours) / Type of supervision, typeofstudents, # of students,School,Location,
date: semesteryear
# of weeks x #hours= / Physical TherapyGeriatrics Supervisor, University ofTexas Medical BranchDepartmentof Rehabilitativeservices.
May 2001 – Oct2004.
9.ResearchActivities
a. Contribution to a research project, supported bya letterfromthe primary investigator ofthepublished researcharticle
1.0 perproject / Dates, title of project,descriptionof role, status ofproject
b. Contribution to a Physical TherapyOutcomeDatabaseSystem
0.5 (per year ofparticipation) / Name ofdatabaseTimeFrame
5
PDP Summary FormsInstructions
1.The following pages contain one blank copy of each of the Professional Development Portfolio(PDP) SummaryFormsonwhichyoushoulddocumentyourprofessionalactivitiessinceyourlastcertification.
2.Each page is a separate form and represents a distinct category of activity (i.e., direct patientcare, teaching, professional services, etc.). The category types are consistent with the list of ABPTSApproved Professional Development ActivitiesSheet.
3.Only use the forms for which you will be submitting evidence to support activity in a specific category. Itis not necessary to submit blank forms for activity categories in which you are not documentingactivities.
4.Candidates are required to obtain PDP activity points in at least 3 approved professionaldevelopmentactivities;foranactivitytocounttowardthisrequirementaminimumofone(1)pointmustbedocumented.
5.Youmaycopytherelevantblankformsasmanytimesasyouneedtoprovidethenecessarydocumentation to support yourrecertification.
6.Please contact a staff member of the Recertification Program if you are unclear as to whether anactivity canbeincludedinthePDP,orifyouhavequestionsaboutwheretorecordtheactivityonthePDPform.
7.Candidates must obtain a minimum of 35 Professional Development Activity (PDA) points. Please donotdocument an excess of 60 professional development activitypoints.
8.Instructions and/or a sample response are provided at the top of each activity sheet. Also, seethe approved Professional Development Activities chartabove.
9.CandidatesmustidentifyanddescribethePDAforeachentryandenterthepointcreditaccordingtothe ABPTS guidelines as indicated in theoverview.
10.CandidatesarerequiredtosubmitsupportingdocumentationofPDAswiththeirsummaryformsunlessotherwise indicated in bold at the top of the activityform.
11.The Specialty Council will conduct random audits of PDPs. If a candidate’s PDP is selected for an audit,(s)he should be able to provide evidence of involvement in PDAs such as W-2s, appointments letters, lettersof attestation,etc.
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Professional Development Portfolio Summary -Geriatrics
Instructions- ProfessionalDevelopmentActivities(PDA)DescriptionofSpecialtyPractice(DSP)–identifythecategoryfortheactivity and enter the point credit according to the ABPTS guidelines. Numbers correspond to ABPTSguidelinenumbers on the Approved Professional Development Activitiessheet.
- Candidates must document activities in a minimum of 3 out of 9 PDAs. A candidate must have earneda
- Minimum Total points required =35
DSPcategoryPatientCare=Nominimumbeyondminimumeligibilityrequirementof2000hoursDSP category Knowledge Base = 4 points minimumrequired
DSPCategory / Professional DevelopmentActivities / Your Points PerPDACategory / Total Points PerDSPCategory
ElementsofPractice(A)
(4 pointsminimum) / 4.Teaching acourse
5. ProfessionalPresentation
6. ProfessionalWriting
7. ProfessionalServices
PatientCare(B) / 1. Direct PatientCare
(20 pointsmax)
8. Clinical Supervision &Consultation
9b. Contributions to PTOutcomesDatabase
KnowledgeBase(C)
(4 pointsminimum) / 2. Participating in CECourse
3. Completion of a college/universitycourse
9a. Contribution to ResearchProject
(An excess of 60 points will result in delayedprocessing/review)TOTAL
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Direct Patient Care – SummaryForm
Professional Development Activity Description – Describe the professional development activityandenter the point credit according to the ABPTSguidelines.
Candidatesmustdocumentprofessionaldevelopmentactivitiesthatreflectthecontentofthe
Description of Specialty Practice(DSP).
Total Direct Patient CareHours from PT ExperienceonlineHours applied toEligibility / 2000 hours if expiring in 2019:
1800 hours if expiring in 2020:
1600 hours if expiring in 2021:
Remaining Hours that canbe
applied toPortfolio / =
Remaining HoursTotalsplit betweenadditionalDirect Patient Care HoursandClinical SupervisionHours activity asappropriate / = / Direct Patient Care –Approved ProfessionalDevelopment
= / Clinical Supervision –Approved ProfessionalDevelopment
Activity#1 / PointValue / Cumulative Points
Direct Patient Care hours in specialtyarea
(beyond minimum eligibilityrequirement) / 0.1 (per 10hours) / 20 pointsmax.
Participation in a Continuing Education Course – SummaryForm
Professional Development Activity Description – Describe the professional development activityandenter the point credit according to the ABPTSguidelines.
Candidatesmustdocumentprofessionaldevelopmentactivitiesthatreflectthecontentofthe
Description of Specialty Practice(DSP).
NOTE: Supportingdocumentationrequired.Pleaseincludespecificcoursedescriptionsforeachcontinuingeducation course attended (i.e. the certificate of completion, course outline, or objectives,etc.)
Activity #2 / Point Value / Cumulative PointsParticipation in a continuing education course with specific goals and objectives related to specialty practice.
Calculations are based on contact hours (class time) rather than quarter or semester course credit hours. (1 Proficiency Point = 10 contact hours, 0.1 Proficiency Point = 1 contact hour) / 1 point per 10 contact hours
Name of course:
Description:
Location:
Date completed:
Number of contact hours:
Certificate of completion required.
Name of course:
Description:
Location:
Date completed:
Number of contact hours:
Certificate of completion required.
Name of course:
Description:
Location:
Date completed:
Number of contact hours:
Certificate of completion required.
Name of course:
Description:
Location:
Date completed:
Number of contact hours:
Certificate of completion required.
Completion of a College/University Course – SummaryForm
Professional Development Activity Description – Describe the professional development activityandenter the point credit according to the ABPTS guidelines. Candidates must documentprofessional development activities that reflect the content of the Description of Specialty Practice(DSP).
Note: Please list each college/university course in form below. Also submit transcript/letterto verifysuccessfulcompletion.(Officialtranscriptsarenotrequired)Unofficialtranscriptsaccepted.
Activity #3 / Point Value / Cumulative PointsSatisfactory completion of a college/university course for credit or audit related to the specialty area / 1 point per course credit hour
Name of course:
Description:
Name of institution:
Date completed: Number of credits:
Name of course:
Description:
Name of institution:
Date completed: Number of credits:
Name of course:
Description:
Name of institution:
Date completed: Number of credits:
Name of course:
Description:
Name of institution:
Date completed: Number of credits:
Name of course:
Description:
Name of institution:
Date completed: Number of credits:
Teaching a Continuing Education or College/University Course – SummaryForm
Professional Development Activity Description – Describe the professional development activityandenter the point credit according to the ABPTSguidelines.
Candidatesmustdocumentprofessionaldevelopmentactivitiesthatreflectthecontentofthe
Description of Specialty Practice(DSP).
NOTE:Pleaseprovideaspecificcoursedescription,andcondensedcoursesyllabiincludingcontact hours,contentdescription,goals,andoutlineofscheduleforeachcoursetaught.
Activity #4 / Point Value / Cumulative PointsTeaching a continuing education course or college/university course related to specialty area.
(Point value decreases for the second time a course is taught. Credit is given only for the first two times a course is taught.)
/ a. First Time = 0.2
(per contact hour)
b. Second Time = 0.1 (per contact hour)
Name of course:
Name of Institution:
Dates (semester):
Number of contact hours:
Syllabus required.
Name of course:
Name of Institution:
Dates (semester):
Number of contact hours:
Syllabus required.
Name of course:
Name of Institution:
Dates (semester):
Number of contact hours:
Syllabus required.
Name of course:
Name of Institution:
Dates (semester):
Number of contact hours:
Syllabus required.
Name of course:
Name of Institution:
Dates (semester):
Number of contact hours:
Syllabus required.
Platform or Poster Presentation at Professional Meeting – SummaryForm
Professional Development Activity Description – Describe the professional development activityandenter the point credit according to the ABPTSguidelines.
Candidatesmustdocumentprofessionaldevelopmentactivitiesthatreflectthecontentofthe
Description of Specialty Practice(DSP).
Note:Pleaseincludesupportingdocumentation,includingplatformorpostertitle,description,date/year of presentation, location.Submit a copy of the presentation, email ofcompletion or program where presentation is listed as supportingdocumentation.
Activity#5a / PointValue / Cumulative PointsProfessional Presentations in specialtyarea.
(Credit is given only for first time a presentation ismade.)
a. Platform or poster presentation at aprofessionalmeeting / 1 perpresentation
Postertitle:
Co-investigator(s):Meetingname: Date:
Postertitle:
Co-investigator(s):Meetingname: Date:
Postertitle:
Co-investigator(s):Meetingname: Date:
Postertitle:
Co-investigator(s):Meetingname: Date:
Postertitle:
Co-investigator(s):Meetingname: Date:
Postertitle:
Co-investigator(s):Meetingname: Date:
Invited Speaker to a Group, Classes or Portions of Courses – SummaryForm
Professional Development Activity Description – Describe the professional developmentactivity and enter the point credit according to the ABPTSguidelines.
Candidatesmustdocumentprofessionaldevelopmentactivitiesthatreflectthecontentofthe
Description of Specialty Practice(DSP).
Note: Please provide evidence of presentation completed, including title, date,group, location and length of talk. Submit a copy of the flyer, sign in sheet, handouts,presentation, or letter from host organization as supportingdocumentation.
Activity #5b / Point Value / Cumulative PointsProfessional Presentations in specialty area.
(Credit is given only for first time a presentation is made.)
b. Invited speaker to a group, glasses, or portion of courses (including in-services) / 0.1 per hour
Presentation title:
Description:
Sponsoring institution:
Location:
Date: Length:
Presentation title:
Description:
Sponsoring institution:
Location:
Date: Length:
Presentation title:
Description:
Sponsoring institution:
Location:
Date: Length:
Presentation title:
Description:
Sponsoring institution:
Location:
Date: Length:
Presentation title:
Description:
Sponsoring institution:
Location:
Date: Length:
Presentations to non-professional community or client-based group – SummaryForm
Professional Development Activity Description – Describe the professional development activityandenter the point credit according to the ABPTSguidelines.
Candidatesmustdocumentprofessionaldevelopmentactivitiesthatreflectthecontentofthe
Description of Specialty Practice(DSP).
Note: Please provide evidence of presentation completed, including the title, date,group, location and length of presentation. Submit a copy of a flyer, letter from host organization,sign in sheet, handouts, or presentation as supportingdocumentation.
Activity #5c / Point Value / Cumulative PointsProfessional Presentations in specialty area.
(Credit is given only for first time a presentation is made.)
b. Invited speaker to a group, glasses, or portion of courses (including in-services) / 0.1 per hour
Presentation title:
Description:
Sponsoring institution:
Location:
Date: Length:
Presentation title:
Description:
Sponsoring institution:
Location:
Date: Length:
Presentation title:
Description:
Sponsoring institution:
Location:
Date: Length:
Authorship – Book Chapters – SummaryForm
Professional Development Activity Description – Describe the professional development activityandenter the point credit according to the ABPTSguidelines.
Candidatesmustdocumentprofessionaldevelopmentactivitiesthatreflectthecontentofthe
Description of Specialty Practice(DSP).
Note: Please provide supporting documentation, including title, name of book, anddate
Can include editor, author, or co-author of publications. Submit a copy first page of eachchapter written and/or table of contents as supportingdocumentation.
Activity #6a / Point Value / Cumulative PointsProfessional Writing - Author or co-author of publications using, “Uniform Requirements for Manuscripts Submitted to Biomedical Journals.”
- Book chapter – multiple number of chapters by 2 points if you wrote more than one chapter or an entire book
Chapter title:
Name of book:
Publication date:
Chapter title:
Name of book:
Publication date:
Chapter title:
Name of book:
Publication date:
Chapter title:
Name of book:
Publication date:
Chapter title:
Name of book:
Publication date:
Chapter title:
Name of book:
Publication date:
Chapter title:
Name of book:
Publication date:
Authorship – Peer Reviewed Journal Article – SummaryForm
Professional Development Activity Description – Describe the professional development activityandenter the point credit according to the ABPTSguidelines.
Candidatesmustdocumentprofessionaldevelopmentactivitiesthatreflectthecontentofthe
Description of Specialty Practice(DSP).
Note: Please provide supporting documentation, including the title, name of publication,and date. Submit a copy of the article as supportingdocumentation.
Activity #6b / Point Value / Cumulative PointsProfessional Writing - Author or co-author of publications using, “Uniform Requirements for Manuscripts Submitted to Biomedical Journals.”
- Peer reviewed journal article
Article title:
Co-author(s):
Name of Publication:
Publication date:
Article title:
Co-author(s):
Name of Publication:
Publication date:
Article title:
Co-author(s):
Name of Publication:
Publication date:
Article title:
Co-author(s):
Name of Publication:
Publication date:
Article title:
Co-author(s):
Name of Publication:
Publication date:
Authorship – Non-Peer Reviewed Publication – SummaryForm
Professional Development Activity Description – Describe the professional development activityandenter the point credit according to the ABPTS guidelines. Candidates must documentprofessional development activities that reflect the content of the Description of Specialty Practice(DSP).
Note: Please provide supporting documentation, including the title, name of publication,and date. Submit a copy of the article as supportingdocumentation.
Activity #6c / Point Value / Cumulative PointsProfessional Writing
- Non-peer reviewed publication
Article title:
Co-author(s):
Name of Publication:
Publication date:
Article title:
Co-author(s):
Name of Publication:
Publication date:
Article title:
Co-author(s):
Name of Publication:
Publication date:
Article title:
Co-author(s):
Name of Publication:
Publication date:
Article title:
Co-author(s):
Name of Publication:
Publication date:
Authorship – Reviews or Commentaries – SummaryForm
Professional Development Activity Description – Describe the professional development activityandenter the point credit according to the ABPTSguidelines.
Candidatesmustdocumentprofessionaldevelopmentactivitiesthatreflectthecontentofthe
Description of Specialty Practice(DSP).
Note: Please provide supporting documentation. Including date, title of review, nameof article, publication. Submit a copy ofreview/commentary.
Activity #6d / Point Value / Cumulative PointsProfessional Writing - Can include editor, author, orco- author of publications using, “Uniform Requirementsfor Manuscripts Submitted to BiomedicalJournals.”
Author
- Reviews or commentaries
Title of review:
Article title:
Publication:
Publication date:
Title of review:
Article title:
Publication:
Publication date:
Title of review:
Article title:
Publication:
Publication date:
Title of review:
Article title:
Publication:
Publication date:
Title of review:
Article title:
Publication:
Publication date:
Title of review:
Article title:
Publication:
Publication date:
Authorship – Case Study or Case Report (Peer Reviewed Journal) – SummaryForm