Section L – Clinical practice reference form – Other clinical health delivery
Reference for:

Dear Colleague

The above applicant has applied for accreditation with Exercise Sports Science Australia (ESSA) as an accredited exercise physiologist (AEP). Applicants may choose to participate in 80 hours supervised clinical placement of other clinical health delivery.

The ‘other’ clinical hours can include:

  1. Provision of exercise delivery for conditions such as cancers, mental health and renal;
  2. Diagnostic investigations or procedures (e.g. cardiac, pulmonary or other clinical investigations or procedures);
  3. Health checks (e.g. point of care testing);
  4. Job capacity assessments, functional capacity assessments;
  5. Laboratory/research testing/screening (in isolation);
  6. Case management;
  7. Health promotion, health education or workplace health programs.

Please complete the following form based on your experience with the above applicant:

Skills and experience

As their supervisor or professional colleague, please confirm in the following table, the applicants evidence for other clinical health delivery: (expand boxes where necessary)

Breakdown of Practicum hours
(≥140 hours) / Total hours and dates* / Evidence of specific roles and duties completed / Site / Location / Applicant has shown appropriate clinical practice
(yes/no, provide
feedback) / Signature of supervisor/ professional colleague
Minimum of 60% (at least 84 hours) of face to face delivery i.e. Individualised/group delivery/instruction of an exercise program. *Testing/assessments without intent for prescription cannot be counted
Maximum of 35% (up to 49 hours) for preparation for face to face delivery, observation and other activities related to the scope of practice of AEPs
Maximum of 5% (up to 7 hours) for administrative tasks
Total hours at this site / 44 hours / ______hours face to face + ______hours preparation + ______hours administration
  • Please note: Students on practicum placement are required to undertake some 1:1 contact with clients and supervisor.

Please turn over

Declaration: (To be completed by each referee (supervisor/professional colleague) listed above). Copy and paste below table as required.

Supervisor/professional colleague 1
I certify that the supplied information is true and correct
Signature / Date
Title / Name
Phone / Email
i. My profession is:
ii. My qualifications in exercise delivery are:
Degree/s: / University: / Country: / Year:
iii. My experience in exercise delivery is: