CREDENTIALED CLINICAL INSTRUCTOR PROGRAM (CCIP)

2017 CCIP Trainer Course Application Packet

The CCIP Trainer Course provides highly-qualified clinical instructors with advanced teaching and instructional capabilities. Upon completion, course participants are awarded Credentialed Clinical Trainer status and are authorized to coordinate and conduct CCIP courses at their discretion.

To be considered for participation, applicants must meet the mandatory eligibility requirements specified below. Please note that meeting these requirements is required for application, but does not guarantee selection. All applications will be reviewed by an advisory workgroup comprised of experienced course trainers, and selections will be made based on strength of application and needs of the program.

Trainer course eligibility requirements include:

status as a licensed physical therapist or physical therapist assistant

membership in APTA or APTA’s International Partners Plan

status as an APTA Credentialed Clinical Instructor

teaching experience including different levels of learners and class size

access to a viable mechanism for the provision of CCIP courses

Experience as a CCCE or as a DCE/ACCE is highly desirable, but not required.

To apply for the course, complete and submit the information beginning on the following pages. Your application must include one letter of recommendation from your supervisor, one letter of recommendation from a peer or colleague, and one letter of recommendation from a student you instructed in the clinic or academic setting. These reference materials may be found at the end of this application document from pages 12-14.

Once you have responded to each self-assessment section and collected your letters of reference, you may submit your completed application parcel via postal mail to:

Credentialed Clinical Instructor Program (CCIP)
American Physical Therapy Association

1111 North Fairfax Street

Alexandria, VA 22314

All application materials must be received or postmarked by December15, 2016. Incomplete applications will not be considered. For further information or assistance, please contact .

2017 CCIP Trainer Course Application

SECTION 1

Applicant Profile

Contact Information
Full Name:
Including credential(s)
Street Address:
City:
State: / Zip
Home Phone:
Cell Phone:
Preferred E-mail:
Professional Details
Professional Designation: / Physical Therapist (PT)
Physical Therapist Assistant (PTA)
APTA ID Number:
State(s) Licensed:
Please include copy of license(s)
Educational Background
Entry-Level Degree: / Type of Degree / Date Received
Highest Degree Earned:
If different than above / Type of Degree / Date Received
CCIP Course Dates:
ACCIP Course Dates:
If applicable
Years of Experience: / Clinician / CI / ACCE/DCE / CCCE
Students supervised: / In Clinic / In Classroom

SECTION 1

Applicant Profile (continued)

Employment History(list most recent first)
Employer 1: / Employer Name
Employed From to / City, State
Position or Title
Responsibilities
Employer 2:
If applicable / Employer Name
Employed From to / City, State
Position or Title
Responsibilities
Employer 3:
If applicable / Employer Name
Employed From to / City, State
Position or Title
Responsibilities
Employer 4:
If applicable / Employer Name
Employed From to / City, State
Position or Title
Responsibilities
Employer 5:
If applicable / Employer Name
Employed From to / City, State
Position or Title
Responsibilities
Employer 6:
If applicable / Employer Name
Employed From to / City, State
Position or Title
Responsibilities

SECTION 1

Applicant Profile (continued)

Professional Activities
List professional activities you have been involved with in the past 5 years specifically related to clinical education (e.g. Section for Education, Clinical Education SIG, clinical education consortia, presentation, chapter and district activities, advocacy, etc.)
Activity 1: / Activity Name
Description
Activity 2:
If applicable / Activity Name
Description
Activity 3:
If applicable / Activity Name
Description
Activity 4:
If applicable / Activity Name
Description
Activity 5:
If applicable / Activity Name
Description
Activity 6:
If applicable / Activity Name
Description
Activity 7:
If applicable / Activity Name
Description
Activity 8:
If applicable / Activity Name
Description
Activity 9:
If applicable / Activity Name
Description
Activity 10:
If applicable / Activity Name
Description

SECTION 1

Applicant Profile (continued)

Professional Development
List continuing education and academic course work you completed during the past 5 yearswhich is specifically related to clinical or academic education.
Course 1: / Course Name
Date (MO/YR) / Sponsor
Description
Course 2:
If applicable / Course Name
Date (MO/YR) / Sponsor
Description
Course 3:
If applicable / Course Name
Date (MO/YR) / Sponsor
Description
Course 4:
If applicable / Course Name
Date (MO/YR) / Sponsor
Description
Course 5:
If applicable / Course Name
Date (MO/YR) / Sponsor
Description
Course 6:
If applicable / Course Name
Date (MO/YR) / Sponsor
Description
Course 7:
If applicable / Course Name
Date (MO/YR) / Sponsor
Description
Course 8:
If applicable / Course Name
Date (MO/YR) / Sponsor
Description

SECTION 1

Applicant Profile (continued)

Teaching Experience
Describe the past four teaching experiences where you had a major teaching role.
Teaching Experience 1: / Learning environment (check appropriate column)
Classroom Instruction / Lab Instruction / Clinical Education / Clinical Instruction / Other Teaching
Topic Area
Taught From to / Number of Learners
Description
Teaching Experience 2:
If applicable / Learning environment (check appropriate column)
Classroom Instruction / Lab Instruction / Clinical Education / Clinical Instruction / Other Teaching
Topic Area
Taught From to / Number of Learners
Description
Teaching Experience 3:
If applicable / Learning environment (check appropriate column)
Classroom Instruction / Lab Instruction / Clinical Education / Clinical Instruction / Other Teaching
Topic Area
Taught From to / Number of Learners
Description
Teaching Experience 4:
If applicable / Learning environment (check appropriate column)
Classroom Instruction / Lab Instruction / Clinical Education / Clinical Instruction / Other Teaching
Topic Area
Taught From to / Number of Learners
Description

SECTION2

Applicant Self-Assessment

Respond to the following statements as candidly as possible to assess your current teaching skills and abilities. Place a check in only one box for each statement.

SA = Strongly Agree; A = Agree; D = Disagree; SD = Strongly Disagree; NO = Not Observed

Command of Materials and Content / Scale
1. I present divergent viewpoints when appropriate. / SA A D SD NO
2. I give examples, illustrations, or applications to clarify abstract concepts. / SA A D SD NO
3. I use alternate explanations when learners do not understand. / SA A D SD NO
4. I demonstrate a thorough knowledge of the material. / SA A D SD NO
Interest in Student/Learners / Scale
5. I listen carefully to comments and questions. / SA A D SD NO
6. I note and respond to signs of learner’s puzzlement or boredom. / SA A D SD NO
7. I support student’s efforts to learn and understand the material. / SA A D SD NO
8. I stimulate learner’s interest in the subject matter. / SA A D SD NO
Interpersonal Skills / Scale
9. I engage the learner in discussion of materials. / SA A D SD NO
10. I tolerate other viewpoints. / SA A D SD NO
11. I receive learner’s questions politely and, when possible, enthusiastically. / SA A D SD NO
12. I display enthusiasm for the subject matter. / SA A D SD NO
Teaching Effectiveness / Scale
13. I clearly state the purpose and goals of the learning experiences. / SA A D SD NO
14. I ask questions to determine what learners know about the topic. / SA A D SD NO
15. I ask different kinds of questions to challenge learners. / SA A D SD NO
16. I ask questions that promote original thinking and evaluative analysis. / SA A D SD NO
17. I present material generally accepted by colleagues as worth knowing. / SA A D SD NO

SECTION 3

Narrative Response

Drawing from your experience as a clinical educator, respond to the questions below in narrative form using the space provided.

3A)You are the Credentialed Trainer for an APTA CCIP course. During a break, you overhear two of the participants discussing the performance of a student with exceptional problems. One of the participants supervised the student during a recent clinical experience in a hospital setting and initiates the conversation with the other participant, who will be supervising the same student during his next clinical experience in an outpatient setting. The student’s clinical experience will begin in one week. You, the Credentialed Trainer, know this student as well.

Identify two issues of concern in this situation, and describe how you would address each situation.

1,600 Character Maximum

SECTION 3

Narrative Response (continued)

3B)You are the Credentialed Trainer for an APTA CCIP course with approximately 40 participants. Two people in the back of the room are disruptive to the group and their ability to learn. These two individuals are now distracting you and your ability to teach the program. The two individuals in the rear of the room are clinical educators who are well known and respected by the professional community. It is your responsibility as the Credentialed Trainer to manage this situation.

Provide two different approaches that mightrealistically be used to manage this scenario. Then identify which alternative you would choose and discuss the reasons why.

1,600 Character Maximum

SECTION 3

Narrative Response (continued)

3C) Complete the following chart based on a focused and planned learning experience that you have developed and implemented for a physical therapist student or aphysical therapist assistant student in the clinical education environment.

The description below must be written in language reflective of specific learning objectives or outcomes to include:

1.Student’s learning needs (i.e. problem list)
2.Sequence of activities
3.List resources used to address learning experience
4.Describe how learning experience was modified based on student performance
5.Provide your evaluation of the learning experience
6.Describe student participation in planning and evaluation of the learning experience

SECTION 4

Applicant Statement

Please use the following space to provide any additional information you would like to share for consideration during your application review process. Please note this statement is optional.

1,000 Character Maximum

Please read the following statement and provide your signature as final verification regarding the contents of your application, the submission of your materials, and the outcome of the selection process. Please note that this step is mandatory and that your application will not be considered in the absence of your signature.

I hereby certify that the information I have provided on this application is true and was completed without assistance from others. I further attest to the integrity of the reference materials submitted on behalf of my application, and affirm that they have been or will be completed voluntarily by others with no guidance or involvement from me. Finally, I understand that the submission of my application and reference materials does not guarantee selection to the CCIP Trainer Course.

Signature of Applicant(electronic signature is acceptable)

APTA TRAINER RECOMMENDATION FORM (SUPERVISOR)

The person for whom you are providing a recommendation is applying to become a trainer for APTA’s Credentialed Clinical Instructor Program (CCIP). Please use this form to assess the applicant's ability as a teacher, regardless of whether instruction occurs in the clinic or academic setting. Place completed recommendation in a sealed envelope and return to the applicant to be included with his/her application.

Applicant's Name

  1. This applicant demonstrates professional and ethical behavior in clinical practice and/or teaching.
/ Yes No
  1. This applicant demonstrates competence and professional skills in clinical practice and/or teaching.
/ Yes No
  1. This applicant has demonstrated a willingness to work with students by pursuing learning experiences to develop knowledge and skills in the academic/clinical setting.
/ Yes No
  1. This applicant demonstrates a systematic approach to patient/client management and/or position responsibilities.
/ Yes No
  1. This applicant uses critical thinking in managing responsibilities or in the delivery of health services.
/ Yes No
  1. This applicant provides rationale for decision making in patient/client management or teaching.
/ Yes No
  1. This applicant demonstrates appropriate time management skills.
/ Yes No
  1. This applicant represents the profession positively by assuming responsibility for self-development and is current regarding professional issues.
/ Yes No
  1. This applicant interacts with patients, students, and other health professionals to achieve identified goals.
/ Yes No
  1. This applicant has an opportunity for providing training to clinical educators in the future.
/ Yes No

Use the area below to provide any additional feedback on this individual’s readiness to take the CCIP Trainer course.

Name of Direct Supervisor (please print)

Title:

Signature of Direct Supervisor (electronic is acceptable)

Date:

APTA TRAINER RECOMMENDATION FORM (PEER/COLLEAGUE)

The person for whom you are providing a recommendation is applying to become a trainer for APTA’s Credentialed Clinical Instructor Program (CCIP). Please use this form to assess the applicant's ability as a teacher, regardless of whether instruction occurs in the clinic or academic setting. Place completed recommendation in a sealed envelope and return to the applicant to be included with his/her application.

Applicant's Name

Directions:Please complete the following recommendation form candidly. Carefully read each statement and check the appropriate response on the scale provided.

SA = Strongly Agree; A = Agree; D = Disagree; SD = Strongly Disagree; NO = Not Observed

Command of Materials and Content / Scale
  1. Presents material generally accepted by colleagues as worth knowing.
/ SA A D SD NO
  1. Gives examples, illustrations, or applications to clarify abstract concepts.
/ SA A D SD NO
  1. Uses alternate explanations when learners do not understand.
/ SA A D SD NO
  1. Demonstrates a thorough knowledge of the material.
/ SA A D SD NO
Interest in Student/Learners / Scale
  1. Listens carefully to comments and questions.
/ SA A D SD NO
  1. Notes and responds to signs of learner’s puzzlement or boredom.
/ SA A D SD NO
  1. Supports student’s efforts to learn and understand the material.
/ SA A D SD NO
  1. Stimulates learner’s interest in the subject matter.
/ SA A D SD NO
Interpersonal Skills / Scale
  1. Engages the learner in discussion of materials.
/ SA A D SD NO
  1. Tolerates other viewpoints.
/ SA A D SD NO
  1. Receives learner’s questions politely and, when possible, enthusiastically.
/ SA A D SD NO
  1. Displays enthusiasm for the subject matter.
/ SA A D SD NO
Teaching Effectiveness / Scale
  1. Clearly states the purpose and goals of the learning experiences.
/ SA A D SD NO
  1. Asks questions to determine what learners know about the topic.
/ SA A D SD NO
  1. Asks different kinds of questions to challenge learners.
/ SA A D SD NO
  1. Asks questions that promote original thinking and evaluative analysis.
/ SA A D SD NO
  1. I would take a course/instruction offered by this person.
/ SA A D SD NO
  1. Under what situation(s) have you observed this individual teach? (Use back of form or attach separate pages.)

Signature of Reviewer (electronic is acceptable)

Date:

APTA TRAINER RECOMMENDATION FORM (STUDENT/LEARNER)

The person for whom you are providing a recommendation is applying to become a trainer for APTA’s Credentialed Clinical Instructor Program (CCIP). Please use this form to assess the applicant's ability as a teacher, regardless of whether instruction occurs in the clinic or academic setting. Place completed recommendation in a sealed envelope and return to the applicant to be included with his/her application.

Applicant's Name

Directions:Please complete the following recommendation form candidly. Carefully read each statement and check the appropriate response on the scale provided.

SA = Strongly Agree; A = Agree; D = Disagree; SD = Strongly Disagree; NO = Not Observed

Command of Materials and Content / Scale
  1. Presents divergent viewpoints when appropriate.
/ SA A D SD NO
  1. Gives examples, illustrations, or applications to clarify abstract concepts.
/ SA A D SD NO
  1. Uses alternate explanations when learners do not understand.
/ SA A D SD NO
  1. Demonstrates a thorough knowledge of the material.
/ SA A D SD NO
Interest in Student/Learners / Scale
  1. Listens carefully to comments and questions.
/ SA A D SD NO
  1. Notes and responds to signs of learner's puzzlement or boredom.
/ SA A D SD NO
  1. Supports student's efforts to learn and understand the material.
/ SA A D SD NO
  1. Stimulates learner's interest in the subject matter.
/ SA A D SD NO
Interpersonal Skills / Scale
  1. Engages the learner in discussion of materials.
/ SA A D SD NO
  1. Tolerates other viewpoints.
/ SA A D SD NO
  1. Receives learner’s questions politely and, when possible, enthusiastically.
/ SA A D SD NO
  1. Displays enthusiasm for the subject matter.
/ SA A D SD NO
Teaching Effectiveness / Scale
  1. Clearly states the purpose and goals of the learning experiences.
/ SA A D SD NO
  1. Asks questions to determine what learners know about the topic.
/ SA A D SD NO
  1. Asks different kinds of questions to challenge learners.
/ SA A D SD NO
  1. Asks questions that promote original thinking and evaluative analysis.
/ SA A D SD NO
  1. I would take a course/instruction offered by this person.
/ SA A D SD NO
  1. Under what situation(s) have you observed this individual teach? (Use back of form or attach separate pages.)

Signature of Reviewer (electronic is acceptable)

Date:

1