Pursuing and Maintaining Accreditation of
Post-Professional Residency Programs
© Commission on Accreditation of Athletic Training Education
CAATE Version 1.3
September 2012, April 2015
Table of Contents
ACCREDITATION OVERVIEW .....................................................................................
Pursuing and Maintaining Accreditation of Post-Professional
Residency Programs in Athletic Training .........................................................................
Accreditation Process.............................................................................................................
Decision to Seek Accreditation ..............................................................................................
Conduct a Self- Study ............................................................................................................
Self-Study Plan of Action ..........................................................................................
Compile a Self-Study Report .................................................................................................
Self-Study Report Format ..........................................................................................
Drafting the Report ....................................................................................................
Sections of the Report ................................................................................................
Submit the Self-Study Report ................................................................................................
Due Dates and Fees ....................................................................................................
What to Submit ..........................................................................................................
Submit to: ...................................................................................................................
Peer Review Process ..............................................................................................................
Site Visit Procedures ..................................................................................................
Itinerary and Interview Schedule ...............................................................................
Visitation of Facilities ................................................................................................
Site Visitation Team Meeting ....................................................................................
Final Meeting with Program Director ........................................................................
Exit Conference .........................................................................................................
Post-Exit Conference .................................................................................................
Site-visitation Team Report .......................................................................................
Recommendation and Formal Action ....................................................................................
Provisional Accreditation ..........................................................................................
Withheld Accreditation .............................................................................................
Maintaining Accreditation ....................................................................................................
Annual Program Fee ..................................................................................................
Annual Reports .........................................................................................................
Program Changes ......................................................................................................
Probation ...................................................................................................................
Withdraw of Accreditation Status ..............................................................................
Voluntary Withdrawal from Accreditation ................................................................
Inactive Probation ......................................................................................................
Forms .....................................................................................................................................
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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ACCREDITATION OVERVIEW
This document supports the current version of the Commission on Accreditation of Athletic
Training Education (CAATE) Pursuing and Maintaining Accreditation of Post-Professional
Athletic Training Residency Standards and Guidelines, hereafter referred to as the Standards and
Guidelines can be found on CAATE website. Its purpose is to provide step-by-step instructions
to post-professional athletic training residency programs that wish to pursue and or maintain
accreditation.
Accreditation is a voluntary, non-governmental peer review process that strives to ensure quality
and accountability, and encourage programmatic improvement. By requesting accreditation, the
sponsoring institution of the graduate degree program agrees to be assessed against the
Standards and Guidelines. The sponsoring institution of an accredited graduate degree program
must comply with these Standards and Guidelines and use them to examine, improve and report
on its program’s growth and achievement.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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The document is organized according to the following aspects of the accreditation process.
I.
Decision to Seek Accreditation
II.
Conduct a Self-Study of the Program to Ensure It Meets the Standards and Guidelines
III.
Compile a Self-Study Report
IV.
Submit a Self-Study Report
V.
Peer Review of Document and Program through On-Site Visit
VI.
Program Response to Site Visit Report
VII.
Annual Report
VIII. Substantive Change
ACCREDITATION PROCESS
I.
Decision to Seek Accreditation
Program personnel, in consultation with the appropriate administrators, make a decision to offer
a post-professional athletic training degree program that meets or exceeds the requirements
specified in the Standards and Guidelines.
Once the decision is made to seek accreditation, the sponsoring body of the program must
register with the CAATE and make formal application for accreditation.
Formal application requires endorsement by the Chief Executive Officer (CEO), Dean (if
applicable), and Program Director of the sponsoring institution. Application does not guarantee
accreditation will be achieved.
The program then begins the comprehensive review process including the self-study and site
visit. The self-study report may only be submitted after all aspects of the program have been
approved and implemented by the sponsoring institution. All aspects of the program must be
functioning at the time the self-study is submitted. The institution should work closely with the
CAATE office staff to allow ample time for the site visit, review of materials, the submission of
a rejoinder, and final review by the Review Committee prior to action taken by the Commission.
II.
Conduct a Self-Study
A self-study is the foundation of the voluntary peer review process of accreditation. It is a critical
and major component of the ongoing program evaluation process, performed as a cooperative
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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effort by individuals with varied interests in program improvement, including the sponsoring
institution’s administration, Program Director, program faculty, preceptors, students and
affiliated clinical staff. (For continuing accreditation, alumni and the employers or supervisors
of program graduates may also be involved).
The self-study process requires a detailed analysis of all aspects of the program including
program sponsorship, outcomes, personnel, program delivery, health and safety, financial
resources, facilities and instructional resources, operational policies and fair practices, program
description and requirements, student records, and distance learning (if applicable). The process
critically examines a program in structure and substance, judges the program’s overall
effectiveness relative to its mission, goals and objectives and its delivery of the professional
competencies (i.e. knowledge, skills and abilities), identifies specific strengths and deficiencies,
and indicates a plan for necessary modifications and continual program improvements.
The information gathered by the program is used to compile a self-study report, which is
submitted to the CAATE electronically in advance of the site visit. The self-study is due by July
1st of the academic year preceding a site visit.
A. Self-Study Plan of Action
1.
Convene a committee of individuals who represent the program and whose primary
focus is to conduct the self-study and develop the self-study report.
2.
Organize the committee early enough to allow ample time to conduct an in-depth,
probing self-study. Most sponsoring institutions begin at least one year in advance.
3.
The committee should be a manageable size, chaired by the program director and
should include faculty, preceptors, administrators, affiliated clinicians, academic
faculty, current students, and alumni. Additional individuals from outside of the main
self-study committee may serve on subcommittees.
4. Assign each committee member to read the Standards and Guidelines and this
document, Pursuing and Maintaining Accreditation of Post-Professional Residency
Programs, so the committee can become thoroughly familiar with the task at hand.
Committee members should review both documents during the first meeting to clarify
any questions or differences of interpretation.
B. Establish a timetable and assign tasks for the completion of the self-study.
C. Collect and summarize existing data about the program’s ability to achieve the stated
mission, goals, objectives, and outcomes of the program. Data should come from conclusions
and reports of previous and ongoing program activities and should be distributed to members
of the self-study committee. The self-study must explicitly identify the extent to which the
graduate degree program is achieving the stated mission, goals, objectives, and outcomes of
the program.
D. Begin gathering program information and drafting the self-study report responses that will be
submitted to the CAATE.
E. Meet regularly to report on assigned tasks, discuss implications of collected data on the
graduate degree program, and receive new assignments. The frequency of such meetings
generally increases as deadlines approach.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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F. Incorporate sufficient quantitative and qualitative information in the self-study report to
provide documentation of your degree program’s compliance with the Standards and
Guidelines. The final draft of the self-study report should reflect the consensus of the selfstudy committee.
III.
Compile a Self-Study Report
The self-study report is an evidential document that summarizes the findings of the self-study
process. The narrative should show the extent to which the graduate degree program is in
compliance with the Standards and Guidelines.
A. Self-Study Report Format
The self-study is completed electronically via email until the time at which eAccreditation
becomes available to Residency Programs. The process includes completion of tables, data entry,
and submission of narratives. The narrative should show the extent to which the residency
program is in compliance with the Standards and Guidelines. The qualitative narrative should
reflect the strengths of the residency program as well as deficiencies or weaknesses, if
applicable, and should include a plan to remedy such limitations.
1. The cover of the self-study document must contain the name of the sponsoring entity.
2. The self-study must be typed and paginated.
3. The text components of the document should be prepared using a Roman font, no
smaller than 12 point.
4. The text component of the document should be single-spaced. The left margin should
be 1.5 in. and all others equal to 1.0 in.
5. Headings must clearly identify each section of the self-study (1-8).
6. Each section (as delineated below) must be its own pdf document when submitted
7. The self-study report and all accompanying materials must be submitted in electronic
format via email to Julie@caate.net. If the size of the files are too large to submit via
email an online shared file system, such as Dropbox, may be used to allow for download
of Self-Study Materials by the CAATE.
B.
1.
2.
3.
Drafting the Report
The report must include the sections detailed below, numbered sequentially as listed
below in Section III.C.
Section III.C.7 corresponds to the six (6) post-professional core competencies of the
Standards and Guidelines. For each of these competencies, create a numeric heading
and bold the name of the competency as a heading, and then address how each core
competency is implemented throughout the residency program. Section III.C.8
corresponds to the Standards associated with the general requirements for athletic
training residencies. For each of the Standards, create a numeric heading, bold each
standard requirement associated with the Standard, and then write the associated
narrative for each standard requirement.
Refer to the glossary of the Standards and Guidelines for clarification of your
responsibility in complying with standards (must/shall) and guidelines (should).
 Standard: Mandatory components of the program. Denoted by the verbs “must
and shall.”
 Guideline: Requirements that are so important that their absence must be
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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justified. Denoted by the verb “should.”
C. Sections of the Report
1.
Cover sheet (Form 1. Available online at http://www.caate.net)
2.
Request for review and evaluation - written request from the Chief Operations
Officer (or equivalent) of the sponsoring organization for the review and
evaluation of the residency program.
3.
Table of contents
4.
Introduction describing the self-study process with a self study committee
signature page that includes the names, credentials, titles, and signatures denoting
approval of the document by each member of the self-study committee.
5.
Sponsoring organization data form (Form 2. Available online at
http://www.caate.net)
6.
Executive summary. Summarize the major strengths of the residency program,
emphasizing the focused area of clinical practice and core competencies. Also
identify major challenges and any changes resulting from the self-study process.
Be brief; 2 pages maximum.
7.
Post-professional core competencies:
In narrative form, explain how the residency addresses each of the six (6) postprofessional core competencies described within the Standards and Guidelines.
Please note that each of the six (6) post-professional core competencies described
must be incorporated within both the didactic and clinical aspect of the residency
program and assessment of each competency must be performed. Examples of
how these competencies are incorporated into the didactic and clinical aspects of
the residency program are encouraged.
8.
Residency Standards: Each Standard should be copied to the document with the
requested materials for each Standard following it. If this Standards file becomes
too large, it may be separated as needed into additional sections/files. Please keep
all of the requested materials for each Standard with the Standard, and refrain
from referencing appendices.
Residency Standards:
1
Accreditation: If the sponsoring organization is an institution of
higher education it must be accredited by an agency recognized by the
United States Department of Education or by the Council for Higher
Education Accreditation and must be legally authorized to provide a
program of post-baccalaureate education. If the sponsoring organization is
an institution of higher education outside of the United States, the
organization must be accredited by a recognized post-baccalaureate
accrediting agency.
 If applicable, Provide documentation verifying the institution is
accredited by an agency recognized by the United States Department of
Education or by the Council for Higher Education Accreditation.
 If outside the United States, the institution must be accredited by a
recognized post-secondary accrediting agency.
2
Program Identity: The name "Athletic Training" must appear as part of
the residency program identity.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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
Indicate how "Athletic Training" is incorporated into the name of the
residency program and the program identity.
3
Affiliation Agreements, Clinical Sites: All sites where residents are
involved in patient care (excluding the residency program's sponsoring
organization) must have an affiliation agreement or memorandum(s) of
understanding that is endorsed by the appropriate administrative authority (i.e.,
those bearing signature authority) at both the sponsoring organization and site. In
the case where the administrative oversight of the resident differs from the
affiliate site, formal agreements must be obtained from all parties.
 Update and Complete Clinical Site Table.
 Provide formal agreements, signed and dated by the appropriate
administrative authority (those bearing signature authority), from both the
sponsoring organization and each site listed on the Clinical Site Table.
 If the administrative oversight of the preceptor differs from the affiliate
site, formal agreements must be obtained from all parties (i.e., if Clinic X
contracts athletic trainers to High School A, then those bearing signature
authority from Clinic X, High School A, and sponsoring organizational
must all sign the formal agreement). (Optional)
 Please note that ALL sites must have affiliation agreements or MOU’s.
Any experience the resident completes as part of their education MUST
have an agreement.
4
Affiliation Agreements, other experiences: In certain instances, the
sponsoring organization of the residency program may establish affiliation with
other units within the organization or at other organization, to provide instruction,
research, or administrative experiences. If such affiliations are made there must be
formal administrative arrangements for use of all affiliated settings.
 If applicable, Provide formal agreements, signed and dated by the
appropriate administrative authority (those bearing signature authority),
from both the sponsoring institution and other institutions, to provide
instruction, research, or administrative experiences.
5
Academic Unit: If the sponsoring organization is an institution of higher
education, the residency program should be housed within the school of health
sciences, health professions, medicine, or similar health-related academic unit.
 Provide a narrative describing where the program is housed.
 If applicable, Provide documentation (catalog, official program
publication) indicating where the program is housed.
6
Practice Settings: Residency programs must be conducted only in those
practice settings where management and professional staff have committed to
seek excellence in patient care, demonstrated substantial compliance with
professionally developed and nationally applied practice and operational
standards, and have sufficient resources to achieve the educational goals and
objectives selected for the residency program.
 Provide a narrative describing how the practice settings utilized by the
residency program are dedicated to seeking excellence in patient care,
demonstrate substantial compliance with professionally developed and
nationally applied practice and operations standards. Additionally
describe how the resources of the practice settings contribute to the
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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achievement of the educational goals and objective selected for the
residency program.
7
Practice Settings: Residency programs, where appropriate, must be
conducted only in practice settings that have sought and accepted outside
appraisal of facilities and patient care practices. The external appraisal must be
conducted by a recognized organization appropriate to the practice setting.
 Provide a narrative describing the appraisal process of the sponsoring
organization's practice setting where the program is housed specific to
facilities and patient care processes. Explain how the external appraiser is
a recognized organization appropriate to the practice setting.
 If applicable, provide documentation of external appraisal of facilities and
patient care practice.
8
Consulting: If the sponsoring organization is not an institution of higher
education it should consult with an individual who is familiar with the
development of objectives, outcomes, educational planning, and the assessment
process.
 Provide a narrative describing how the sponsoring organization developed
objectives, outcomes, educational planning, and the assessment process.
9
Multiple Sponsoring Organizations: Two or more practice sites, or a
sponsoring organization (e.g., colleges/universities, health system) working in
cooperation with one or more practice sites, may provide an athletic training
residency.
 If applicable, provide a narrative describing how multiple organizations
work in cooperation to provide a residency, including how aspects of the
Residency are shared between organizations, and designating Personnel
for responsible for carrying out aspects of the program
 If applicable, Provide copies of the agreements existing between multiple
sponsoring organizations.
10
Program requirement(s) support: Athletic training residencies must
demonstrate the availability of a sufficient patient population base and
professional practice experience to satisfy the requirements of the residency
program.
 Provide narrative describing the patient population base served by the
residency program and how the professional practice experience satisfies
the requirements of the residency program
11
Sponsoring Organization Responsibility: Sponsoring organizations must
maintain authority and responsibility for the quality of their residency program.
 Provide a narrative describing how authority and responsibility for the
quality of the residency program is maintained by the sponsoring
organization.
12
Program Director support: A mechanism must be established that
designates and empowers an individual to be responsible for directing the
residency program and for achieving consensus regarding the evaluation and
ranking of applicants for the residency.
 Provide a narrative describing how the residency program director is given
the autonomous responsibility for directing the program and for directing
resident application and admissions.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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
Provide a copy of the Residency Program Director's job description
indicating responsibilities pertaining to the direction of the program and
selection of resident applicants.
13
Facility Principles: All sites where residents are involved in patient care
must adhere to the BOC Facility Principles
 Provide a narrative describing how the sponsoring organization verifies
and assesses all clinical sites at which residents provide patient care for
adherence to the BOC Facility Principles.
 Provide copies of clinical site evaluations for all sites where residents
provide patient care.
14
Outcomes and Objectives, Develop a Plan: The residency program's
outcomes and objectives guide the residency program, and must be consistent
with the mission of the sponsoring organization, and the department in which the
program is housed.
 Provide a narrative describing how the program’s outcomes and objectives
guide the program and are consistent with the mission of the sponsoring
organization, and department.
 Provide copies of the mission of the Sponsoring organization, and
department in which the program is housed.
 Provide copies of the program’s mission, goals, outcomes, and objectives
15
Outcomes and Objectives, Develop a Plan: All aspects of the residency
program (clinical practice, didactic, and scholarly experiences) must have
corresponding residency program outcomes and objectives.
 Provide a narrative describing how all aspects of the program (clinical
practice, didactic, scholarly experience) have corresponding residency
outcomes and objectives.
 Provide copies of the program’s mission, goals, outcomes and objectives
that documents all aspects of the program related to one or more
corresponding outcomes and objectives.
16
Preceptor expertise, Develop a Plan: The residency program's outcomes
and objectives must reflect its preceptor's expertise and resources.
 Provide a narrative describing how the program’s outcomes, goals and
objectives reflect the preceptor's expertise and resources.
17
Residents' development, Develop a Plan: The residency program's
outcomes must increase residents' depth and breadth of understanding of athletic
training subject matter areas, skills, and Post-Professional Core-Competencies,
beyond the knowledge, skills, and abilities required of a professional preparation
program.
 Provide a narrative describing how the program’s outcomes increase
residents’ depth and breadth of understanding of the athletic training
subject matter areas, skills, and Post-Professional Core-Competencies
beyond those of professional program preparation.
 Provide copies of documents utilized by the program to verify how the
outcomes increase a resident’s depth and breadth of understanding.
18
Comprehensive Assessment Plan, Develop a Plan: There must be a
comprehensive assessment plan to evaluate all aspects of the residency program.
Assessments used for this purpose must include those defined in the overall plan.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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Additional assessments may include, but are not limited to, clinical site
evaluations, preceptor evaluations, academic course performance, retention and
graduation rates, graduating resident exit evaluations, and alumni placement rates
one year post graduation.
 Provide the program’s comprehensive assessment plan including including
program outcomes and resident learning outcomes.
 Provide a narrative explaining what assessments are completed, to whom
they are given, and when, where, why, and how they are disseminated.
19
Ongoing Assessment, Develop a Plan: The plan must be ongoing and
document regular assessment of the residency program.
 Provide a narrative describing how the assessment plan is ongoing and
documents regular assessment of the education program.
20
Assessment Measures: The residency program's assessment measures
must include those stated in the overall plan. The specific volume and nature of
this information is influenced by the individual character of the organization and
should be in keeping with other similar residency programs within the
organization. The assessment tools must related to the program's stated
educational mission, goals, and objectives.
 Provide the program’s mission, goals and objectives.
 Provide the assessment tools that measure quality of instruction, student
learning, and overall program effectiveness.
 Provide a narrative describing how each assessment tool is used to
measure quality of instruction, student learning, and overall program
effectiveness as they relate to the program’s educational mission, goals
and objectives.
21
Aggregate data, Assessment Measures: The residency program's aggregate
organizational data for the most recent three years must be provided.
 Provide a copy of the program’s aggregate institutional data (as defined by
the CAATE).
22
Public Accessibility, Assessment Measures: Residency programs must
post the aggregate organizational data (as defined by the CAATE) on the
residency program's home page or a direct link to the data must be on the
residency program's home webpage.
 Provide a screen shot of the home page that shows either the program’s
aggregate data (as defined by the CAATE) or the link to the program’s
aggregate data.
23
Data Collection, Collect the Data: Residency programs must obtain data to
determine all identified residency program outcomes.
 Provide the program’s mission, goals and objectives.
 Provide data from resident assessment tools that clearly demonstrate
quality of instruction.
 Provide data from resident assessment tools that clearly demonstrate the
achievement of resident learning.
 Provide data from resident assessment tools that clearly demonstrate
overall program effectiveness.
 For each data point provided above, explain how the outcome meets the
program’s mission, goals and objectives.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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24
Data Analysis: Residency programs must analyze the outcomes data to
determine the extent to which the residency program is meeting its stated mission,
goals, and objectives
 Provide a narrative on how the program analyzes outcome data to
determine the extent to which it meets the program’s stated mission, goals,
and objectives.
 Provide results and/or summary data of each program and resident
learning outcome.
25
Action Plan: The results of the data analysis are used to develop a plan for
continual residency program improvement. This plan must:
a. Develop targeted goals and action plans if the residency program and resident
learning outcomes are not met; and
b. State the specific timelines for reaching those outcomes; and
c. Identify the person(s) responsible for those action steps; and
d. Provide evidence of periodic updating of action steps as they are met or
circumstances change.
 Provide a narrative explaining how the program achieved or did not
achieve the program and student learning outcomes.
 If applicable, for any outcome not met, explain the program’s action plan
and delineate a specific timeline for reaching the desired outcome.
 Identify the individual(s) who is (are) responsible for developing,
implementing, and monitoring the action steps within the program’s plan.
 Provide evidence of how the program has updated their action steps or
long-term goals once the previous outcomes have been met or
circumstances have changed.
26
PD requirements: The Residency Program Director must be a full-time
employee of the sponsoring organization.
 Provide documentation verifying the Program Director’s full time
employment at the sponsoring organization.
27
PD requirements: The Residency Program Director should have a
minimum of five years of athletic training practice experience.
 Provide documentation verifying the Program Director's experience in
athletic training.
28
PD requirements: The Residency Program Director should have
demonstrated mastery of the knowledge, skills, attitudes, and abilities expected of
one who has completed a residency.
 Provide a narrative describing the Program Director's mastery of the
knowledge, skills, attitudes, and abilities expected of one who has
completed a residency.
 Provide documentation supporting the Program Director's mastery of the
knowledge, skills, attitudes, and abilities expected of one who has
completed a residency.
29
PD requirements: The Residency Program Director must have
programmatic administrative and supervisory assignment that is consistent with
other similar assignments within the organization.
 Provide the Program Director’s job description.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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
Provide a narrative explaining programmatic administrative and
supervisory responsibility and how this position is consistent with other
similar assignments at the organization.
30
PD requirements: Each residency program must have a single Residency
Program Director who must be an athletic trainer from a practice site involved in
the program or from a sponsoring organization.
 Provide the Program Director’s job description.
31
PD requirements: A single Residency Program Director must be
designated for multiple-site residencies or for a residency offered by a sponsoring
organization in cooperation with one or more practice sites.
 Provide the Program Director’s job description.
32
PD Responsibilities: The responsibilities of the Residency Program
Director must be defined clearly, including lines of accountability for the
residency and to the residency training site.
 Provide the Program Director’s job description.
33
PD Contract: The designation of this individual to be Residency Program
Director must be agreed to in writing by responsible representatives of each
participating organization.
 Provide the Program Director's contract signed by all appropriate
responsible representatives.
34
PD requirements: The Residency Program must have demonstrated their
ability to direct and manage an athletic training residency. This may include, but
is not limited to previous involvement as a preceptor in a CAATE accredited
athletic training residency program, management experience, or previous clinical
instruction or supervision experience.
 Provide the Program Director’s resume or curriculum vitae.
 Provide a narrative explaining the Program Director's previous experience
demonstrating their ability to direct or manage an athletic training
residency.
35
PD requirements: The Residency Program Director must have a sustained
record of contribution and commitment to athletic training practice. The record
may include, but is not limited to, the following characteristics:
a. Documented record of improvements in, and contributions to, athletic training
practice.
b. Formal recognition by peers or supervisors as a model practitioner.
c. An ongoing record of continued contribution to the total body of knowledge in
athletic training through publications in professional journals and/or presentations
at professional meetings.
d. Demonstrated leadership in advancing the profession of athletic training
through active service in professional organizations and activities at the local,
state, and national levels.
e. Demonstrated effectiveness in teaching (e.g. through student and/or resident
evaluations, teaching awards).
 Provide narrative describing the Residency Program Director's record of
contribution and commitment to athletic training practice.
 Provide the Program Director's resume or curriculum vitae.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
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
Provide evidence of contribution and commitment to athletic training
practice.
 Provide evidence of effectiveness in teaching.
36
PD Release Time: The Residency Program Director must have
administrative release time. The Residency Program Director's release time must
be equivalent to similar residency programs in the organization. If no such similar
program exists at the organization, then benchmark with peer organizations.
 Submit PD Workload Table that includes a breakdown of the Program
Director’s administrative, teaching, service, and scholarship workload.
 Provide a narrative explaining the Program Director’s administrative
release time.
 Provide a narrative explaining how the Program Director’s workload
compares to similar positions at the sponsoring organization and how it
compares to sponsoring organization policy.
37
PD Responsibilities: The Residency Program Director's responsibilities
must include input to, and assurance of, the following residency program
features:
a. Ongoing compliance with the Standards;
b. Planning, development, implementation, delivery, documentation, and
assessment of all components of the residency program;
c. Clinical practice experiences;
d. Programmatic budget
 Provide a narrative that explains the Program Director’s extent of
involvement, input and assurance of the program features identified in
Standard 37.
38
PD Qualifications: The Residency Program Director must be certified and
be in good standing with the Board of Certification (BOC)
 Provide a copy of current BOC card or on-line verification of credential
for the Program Director.
39
PD Qualifications: The Residency Program Director must possess a
current state athletic training credential and be in good standing with the state
regulatory agency (where applicable)
 Provide verification of current state credential, or documentation
indicating a lack of need for state credential when applicable, for the
Program Director.
40
PD Effectiveness: The Residency Program Director must have
documented evidence of his/her own ability to teach effectively in the clinical
practice environment (e.g., through student and/or resident evaluations).
 Provide evidence of effectiveness in teaching.
41
PD Mentorship: The Residency Program Director must mentor the
preceptors as they interact with the resident.
 Provide narrative describing the mentorship process between the Program
Director and the Preceptors.
42
Preceptor Quantity: The residency program must provide a sufficient
complement of associated clinical staff (preceptors and other clinicians) to ensure
appropriate support and guidance to all residents.
 Provide Preceptor Table
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14

Explain how residents are advised, the average number of residents per
preceptor, and how this is comparable to other programs at the
organization. If no such programs exist within the sponsoring organization
benchmark with peer programs/organizations.
43
Preceptor Quantity: Based on the residency program's resident enrollment,
the number of clinical staff (preceptors and other clinicians) must be sufficient to
meet residency program outcomes.
 Discuss how the number of preceptors and other clinicians contributes to
the achievement of the program’s outcomes.
44
Preceptor Responsibilities: A preceptor must function to:
a. Mentor residents during clinical practice to expand their depth and breadth of
knowledge and skills in the programs focused area of clinical practice;
b. Provide instruction and assessment of the advanced knowledge, skills, and
clinical abilities of the focused area of clinical practice designated by the
program;
c. Provide instruction and opportunities for the resident to develop advanced
clinical integration proficiencies, communication skills, and clinical decisionmaking during actual patient/client care;
d. Provide assessment of athletic training residents' clinical integration
proficiencies, communication skills, and clinical decision-making during action
patient/client care;
e. Facilitate the clinical integration of advanced skills, knowledge, and evidence
regarding the practice of athletic training in the programs focused area of clinical
practice.
 Provide a narrative describing how all preceptor and clinicians are
informed of, instruct to expand the depth and breadth, and facilitate the
integration of the athletic training knowledge, skills, and abilities.
 Provide a narrative describing how preceptor mentorship occurs, how the
residents are instructed and assessed on advanced clinical integration
proficiencies, communication skills, and clinical decision-making.
45
Preceptor Compliance : A preceptor must demonstrate understanding of
and compliance with the program's policies and procedures.
 Provide a narrative describing how preceptors are instructed on program
policies and procedures.
 Provide the program's policies and procedures.
46
Preceptor Qualifications: A preceptor must be credentialed by the
state in a health care profession.
 Provide Preceptor Table
 Provide a copy of current BOC card or on-line verification certification for
every preceptor listed on Preceptor Table.
 Individuals not holding BOC certification must provide verification of
appropriate current practice credential.
47
Preceptor Training: All preceptors must have training and experience
in the focused area of clinical practice for which they serve as preceptors,
must maintain continuity of practice in that area, and must be practicing in
that area at the time residents are being trained.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
15

Provide a narrative describing the training and experience of preceptors
relative to the focused area of clinical practice.
 Provide a copy of resume/curriculum vitae for all preceptors responsible
for supervising or mentoring residents.
48
Preceptor Training: A preceptor must receive planned and ongoing
education from the program designed to promote a constructive learning
environment.
 Provide a narrative describing the type and timing of preceptor education.
49
Preceptor Qualifications: Preceptors must have a record of contribution
and commitment to their focused area of clinical practice. The record may
include, but is not limited to, the following characteristics:
a. Documented record of improvements in, and contributions to, their focused
area of practice.
b. Formal recognition by peers or supervisors as a model practitioner.
c. An ongoing record of continued contribution to the total body of knowledge in
their specified area of practice through publications in professional journals
and/or presentations at professional meetings.
d. Demonstrated leadership in advancing their profession through active service in
professional organizations and activities at the local, state, and national levels.
e. Demonstrated effectiveness in teaching (e.g. through student and/or resident
evaluations, teaching awards).
 Provide narrative describing Preceptors' record of contribution and
commitment to their profession.
 Provide Preceptors' resume or curriculum vitae.
 Provide evidence of preceptor contribution and commitment to their
profession.
 Provide evidence of preceptor effectiveness in teaching.
50
Medical Director: The residency program must have a Medical Director.
This individual must be an MD/DO who is licensed to practice in the state
sponsoring the program
 Provide Medical Personnel Table
 Provide current state credentials for the Medical Director.
51
Medical Director Role: The Medical Director must, in coordination with
the Residency Program Director, serve as a resource and medical content expert
for the residency program
 Provide a narrative explaining how the Medical Director works in
coordination with the Program Director and serves as a resource and
medical content expert for the program.
52
Resident Didactic Education: The residency program must provide
defined and planned didactic education experiences in a focused area of clinical
practice within the scope of athletic training
 Provide a narrative detailing the didactic education experiences provided
to residents relative to the focused area of clinical practice.
53
Resident scholarly experienceThe residency program must provide a
defined and planned scholarly experience within the focused area of clinical
practice.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
16

Provide a narrative explaining sufficient time and opportunities are
provided for the residents to engage in scholarly experiences.
 Provide copies of the assessments used to document resident engagement
in scholarly experiences.
54
Core Competencies: The residency program must assure that the PostProfessional Core Competencies are integrated within the program
 Provide a narrative explaining how the Post-Professional Core
Competencies are integrated within the program.
55
Non-discriminatory Practices: Clinical placements must be nondiscriminatory with respect to race, color, creed, religion, ethnic origin, age, sex,
disability, sexual orientation, or other unlawful basis.
 Describe how the program ensures that residents have equal opportunities
for clinical placements.
56
Site Evaluation: All sites must be evaluated by the residency program on
an annual and planned basis and the evaluations must serve as part of the
residency program's comprehensive assessment plan.
 Describe how the program evaluates education sites on an annual and
planned basis and how the evaluations serve as part of the program’s
comprehensive assessment plan.
 Discuss how your outcomes demonstrate achievement of this standard.
57
Resident BOC Verification: The residency program's residents must be
credentialed and be in good standing with the Board of Certification (BOC) prior
to providing athletic training services.
 Provide a copy of the Resident Table.
 Provide a copy of current BOC card or on-line verification of credential
for each Resident listed on the Resident Table. (Required upload multiple uploads)
58
Resident State Credential: The residency program's residents must possess
a current state athletic training credential and be in good standing with the state
regulatory agency (where applicable) prior to providing athletic training services.
 Provide a copy of the Resident Table. (Required upload)
 Provide verification of current state credential for the each resident listed
on the Resident Table.
59
Resident Educational Opportunities: Planned and ongoing educational
opportunities (minimum requirement of five hours per week) must be documented
that the resident must complete throughout the residency. These may include, but
are not limited to, case reviews, didactic classroom instruction, journal club,
problem solving sessions, clinical rounds, in-services, seminars, workshops, etc.)
 Provide a narrative explaining the amount and type of the educational
opportunities that are provided for the residents.
 Provide copies of the assessments used to document resident engagement
in educational experiences.
60
Resident hours policy:The number of work hours performed during the
residency program must be in compliance with organizational and Federal policy
and must not exceed the duty hour standards of the Accreditation Council for
Graduate Medical Education (ACGME)
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
17

Provide a narrative explaining how the program ensures the number of
work hours performed during the residency program is in compliance with
organizational, Federal policy, and the duty hour standards of the
ACGME.
 Provide a copy of the organizational policy on number of work hours
performed.
 Provide documentation verifying the number of work hours performed
during the residency is in compliance with organizational, Federal policy,
and the ACGME standards.
61
Evidence Based Practice: The residency program must provide
opportunities for the residents to instill the principles of evidence-based practice
to include, but not limited to, reading an interpreting available patient oriented
evidence and integrating into clinical practice
 Provide a narrative explaining how the program provides opportunities for
residents to instill the principles of evidence-based practice.
 Provide copies of the assessments used to demonstrate integration of
evidence-based practice into clinical practice.
62
Research review: The residency program must provide opportunities for
residents to identify, assimilate, and review research within the focused area of
clinical practice and disseminate the information that has been compiled
 Provide a narrative describing how the program provides opportunities for
residents to identify, assimilate, and review research in a focused area, and
where applicable how compiled information is disseminated.
 When applicable provide documentation (i.e. Publications, conference
presentations, etc) as evidence of the dissemination of new knowledge
emanating from the program’s assimilation and review of research.
63
Patient Oriented Evidence: The residency program must incorporate the
principles of evidence based practice and include the measurement of patient
oriented evidence to determine the effectiveness of athletic training interventions.
 Provide a narrative explaining how the program measures patient oriented
evidence to determine the effectiveness of athletic training interventions.
 Provide copies of the assessments used to demonstrate that the principles
of evidence based practice impacted patient oriented evidence.
64
Patient outcomes dissemination: The resident must actively engage in
measuring patient oriented outcomes as part of systematic data collection and
ongoing assessments within the focused area of clinical practice, and disseminate
the information that has been compiled.
 Provide a narrative explaining how the residents collect patient oriented
outcomes and other data within the focused area of clinical practice.
 When applicable, provide documentation (i.e. Publications, conference
presentations, etc) as evidence of the dissemination of new knowledge
emanating from the residents' collection of patient oriented outcomes and
other data within the focused area of clinical practice.
65
Resident Feedback: Residents must receive formal and informal feedback
regarding their performance at regularly planned intervals.
 Provide a narrative describing how and when residents receive formal and
informal feedback regarding their performance.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
18

Provide copies of the formal and informal feedback provided to the
residents regarding their performance.
66
Resident Goals/Objectives: There must be an individualized advanced
clinical education plan (individual goals and/or objectives) for each resident to
improve the residents' ability to provide patient care.
 Provide a narrative describing how individualized advanced clinical
education plans are developed for each resident to improve the resident’s
ability to provide patient care.
 Provide a copy of the Resident Table.
 Provide a copy of the individualized advanced clinical education plan for
two residents listed in the Resident Table that ensures improvement of the
resident’s ability to provide patient care.
67
Residency Timeframe: Residency programs must be a minimum of twelve
consecutive months with a continuous full-time practice commitment
 Provide Individual Resident Assignment Table
 Provide documentation detailing start and end dates of residency program
for all residents included in the Individual Resident Assignment Table
68
Resident and Patient Welfare: The Residency Program Director must
ensure that neither the educational outcomes of the program nor the welfare of the
resident or the welfare of patients are compromised by excessive reliance on
residents to fulfill service obligations .
 Provide a narrative detailing how the Residency Program Director ensures
that neither the educational outcomes of the program nor the welfare of the
resident or the welfare of the patients are compromised by excessive
reliance on residents to fulfill service obligations.
69
The Residency Program Director and, when applicable, preceptors must
conduct essential orientation activities. Residents must be oriented to the program
to include its purpose, the applicable accreditation regulations and standards,
designated learning experiences, and the evaluation strategy. When necessary,
the Residency Program Director will orient staff to the residency program.
Preceptors will orient residents to their learning experiences, including reviewing
and providing written copies of the learning experience education goals and
objectives, associated learning activities, and evaluation strategies.
 Provide a narrative describing how orientation for the residents is
provided, and if applicable how staff is oriented to the residency program.
 Provide a narrative describing how preceptors orient residents to their
learning experiences.
 Provide copies of the written learning experience goals and objectives,
associated learning activities, and evaluation strategies that are provided to
the residents during preceptor orientation.
70
Program Budget: The residency program must receive adequate, equitable,
and annually available resources necessary to meet the program's needs based on
the program's size and documented mission and outcomes. Funding must be
commensurate with other comparable residency programs. If no such similar
residency program exists at the organization, then benchmark with residency
programs at peer organizations.
 Submit Budget Table.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
19

Provide a narrative describing how the program receives adequate,
equitable and annually available resources necessary to meet the
program’s needs based on the program’s size and documented mission and
outcomes.
 Provide a narrative describing how the program’s budget is comparable to
other health care programs at the organization (or at benchmark
organizations, if necessary).
71
Resident financial support: The residency program must provide residents'
sufficient financial support to fulfill the responsibilities of the program.
 Provide a narrative describing how the financial support provided to the
residents is sufficient to fulfill the responsibilities of the program.
72
Clinical & Didactic Space: Clinical and didactic space must be sufficient
to deliver the residency program
 Provide a narrative describing clinical and didactic space designated for
education.
 If space is shared with other entities, provide documentation verifying
exclusive use during normally scheduled educational times.
73 Instructional Aids: The number and quality of instructional aids must meet the
needs of the residency program's focused area of clinical practice.
 Submit a narrative describing how the number and quality of instructional
aids meet the needs of the program, specifically the program’s focused
area of clinical practice.
74 Library & Informational Sources: Residents must have reasonable access to
the information resources needed to adequately prepare them for advanced
practice and to support the Post-Professional Core Competencies. This
includes current electronic or print editions of books, periodicals, and other
reference materials and tools related to the program outcomes.
 Provide a narrative describing the nature and extent of resources available
to residents in the program.
75 Residency staff Office Space: Offices must be provided for residency program
staff on a consistent basis to allow for program administration and confidential
resident counseling.
 Provide a narrative describing how the office space provided for residency
program staff allows for program administration and confidential resident
counseling.
76
Resident work space The residency program must provide residents an
area in which to work
 Provide a narrative describing the work space provided for residents.
77
Program Admission Standards: Standards and criteria for Residency
Program admission and retention must be identified and publicly accessible.
 Provide Program Description and Accessible Documents Table.
 Provide copies of all documents from each source as indicated on Program
Description and Accessible Documents Table used for admission to the
program and retention.
 Indicate where the admission standards and criteria are published in
publicly accessible documents.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
20
78
Employment Practices: Employment practices must be non-discriminatory
with respect to race, color, creed, religion, ethnic origin, age, sex, disability,
sexual orientation, or other unlawful basis.
 Describe how the program ensures that resident and staff recruitment,
resident admission, and staff employment are non-discriminatory with
respect to race, color, creed, religion, ethnic origin, age, sex, disability,
sexual orientation, or other unlawful basis.
79
Resident Opportunities: The residency program must assure equal
opportunity for didactic instruction, clinical experience, and other educational
activities for all residents in the program.
 Describe how the program ensures that all residents have equal
opportunities for instruction, clinical experience, and other educational
activities.
80
Terminology: All program documents must use accurate terminology of
the profession and residency program offered (e.g., BOC certification,
accreditation status, and the residency program title of athletic training).
81
Residency Program Cost: All required program specific costs incurred by
the resident must be publicly accessible in official organizational documents.
 Provide Program Description and Accessible Documents Table.
 Provide copies of all documentation from all sources as indicated on
Program Description and Accessible Documents Table.
82
Resident Acceptance: Acceptance by residents of these terms and
conditions must be documented prior to beginning of the residency.
 Provide copies of documents signed by residents accepting terms and
conditions of the residency program.
83
Residency Program Leave Policy: Organizational policies concerning
professional, family, and sick leave and the effect such leaves would have on the
resident's ability to complete the residency program must be defined, published,
and readily available
 Provide a copy of the organization’s policy and processes for resident
professional, family, and sick leave and the effect such leaves would have
on the ability to the complete the residency program.
 Identify how the policy and processes are made available to applicants.
84
Resident Credentials: The resident must be appropriately credentialed to
practice athletic training in the state of the residency
 Provide a copy of the Resident Table.
 Provide verification of current state credential for the each resident listed
on the Resident Table.
85
Resident Commitment: The residents' primary professional commitment
must be a full-time obligation to the residency program.
 Provide a narrative detailing how the Residency Program Director ensures
that the residents' primary professional commitment is full-time obligation
to the residency program.
86
Residency Description: Preceptors and residents must have a clearly
written and consistent description of the residency program available to them.
 Submit Program Description and Accessible Documents Table.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
21
87
Residency Description: The description of the residency program must
include residency program mission, outcomes, and objectives
 Provide a copy of the program’s mission, goals, and objectives.
88
Residency Description: The description of the residency program must
include didactic and clinical practice sequence.
 Provide a copy of the program’s didactic and clinical practice sequence.
89
Residency Description: The description of the residency program must
include program requirements for completion of the residency
 Provide a copy of the program’s requirements for completion.
90
Grievance Policy: The sponsoring organization must have a published
procedure available for processing resident and preceptor grievances.
 Provide a copy of the organization’s resident and preceptor grievance
policies and processes.
91
Withdrawal Policy: Policies and processes for resident withdrawal and
termination must be published in official organizational publications or other
announces information sources and made available to applicants.
 Provide a copy of the organization’s and/or program's policy and
processes for resident withdrawal.
 Identify how the policy and processes are made available to applicants.
92
Scholarship Policy: Policies and procedures governing the award of
available funding for scholarships administered by the program must be
accessible by eligible residents.
 Provide a copy of the policy and procedures for scholarship funding.
 Describe residents are notified of scholarship opportunities.
93
Education and Training: The residency program must provide defined,
planned, and mentored education and training in a focused area of clinical
practice within the scope of athletic training.
 Provide a narrative describing how education and training in a focused
area of clinical practice is provided in a defined, planned, and mentored
manner.
94
Clinical Practice Environment: The organization offering the residency
program must provide an exemplary clinical practice environment and mentored
athletic training experience.
 Provide a narrative describing how the organization offers an exemplary
clinical practice environment and mentored athletic training experience.
95
Planned Clinical Experience: The residency program must document that
the clinical practice environment involves a defined and planned experience
within a focused area of clinical practice within the scope of athletic training.
 Provide a narrative describing the clinical practice environment relative to
the focused area of clinical practice within the scope of athletic training.
 Provide copies of the documentation utilized to ensure that defined and
planned experience within a focused area of clinical practice within the
scope of athletic training
96
Focused Clinical Experience: The majority of the clinical experience must
be completed within the focused area of clinical practice, and at least 20% of the
time must occur with the preceptors in a one-on-one basis within that focused
area.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
22

Provide a narrative describing how program ensures that the majority of
clinical experience is completed within the focused area of clinical
practice, and at least 20% of the time occurs with the preceptors in a oneon-one basis within that focused area.
97
Resident Employment: Residents should be employees of the sponsoring
organization
 Provide documentation verifying the employment of the residents by the
sponsoring organization.
98
Resident Progression: The residency program must maintain appropriate
resident records demonstrating progression through the residency program.
 Provide a narrative describing how resident records are maintained to
demonstrate progression through the program.
99
Record Inclusion: The residency program must maintain appropriate
resident records. These records, at a minimum, must include residency program
admission application and supporting documents.
 Submit Resident Records Table.
 Provide one blank copy of the program’s admission application and each
supporting document used in the admission process.
100
Record Inclusion: The residency program must maintain appropriate
resident records. These records, at a minimum, must include remediation and
disciplinary actions (when applicable).
 Provide a narrative describing how remediation and disciplinary actions
are addressed.
 Provide documentation used to address remediation and disciplinary
actions for a current resident (last name blinded) in the program, if
applicable.
101
Record Inclusion: The residency program must maintain appropriate
resident records. These records, at a minimum, must include clinical practice
experiences
 Submit Resident Table.
 Submit Individual Resident Clinical Assignment Tables.
102
Resident records must be stored in a secure location(s), either electronic or
in print, and be accessible to only designated residency program personnel.
 Provide a narrative describing the secure location of the student records
and who has access to them.
IV.
Submit the Self-Study Report
A. Due Dates and Fees
1. The completed self-study must be submitted to the CAATE by July 1 for scheduling of
an on-site visitation during that upcoming academic year (e.g. July 1, 2015 for a 20152016 academic year visit). Failure to meet this deadline precludes evaluation of the
proposed program during the year requested.
2.
A non-refundable self-study fee (http://caate.net/rp-accreditation-fees/), payable to
the CAATE, must be submitted prior to the review of the self-study materials. This
$500 fee covers the review of the self-study. The non-refundable fee may be submitted
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
23
by check or credit card. Please contact accounting@caate.net for instructions.
3.
The initial or continuing Application for Accreditation Services (Self-Study) for the 2015-2016
academic year, and the associated fee of $500, made payable to the CAATE, is due in the
CAATE Office when the self-study is submitted. If the program wishes to receive the invoice
prior to the actual submission of the self-study, program administrators may request the invoice
by emailing accounting@caate.net. The $500 fee is for the review of self-study materials. No
program will be reviewed until the Self-Study Fee is paid. Upon the determination that a site
visit is appropriate the program will be required to pay Site Visit costs of $250 honorarium per
site visitor program, plus all associated fees with Site Visit, including travel, hotel, foot, etc.
B.What to Submit
1. The Self-Study Report and all accompanying files and supporting materials must be
submitted electronically to Julie@caate.net . Once the files are submitted, an invoice will
be generated electronically. The invoice may be paid by credit card or a check may be
mailed to the address on the invoice.
2. Program materials will not be reviewed until the fee is received.
V.
Peer Review Process
The second part of the Comprehensive Review Process involves a site visit conducted by
peer evaluators using the same set of review criteria (Standards) as was used in the selfstudy process. The responsibility of the peer reviewers is to validate the information and
findings identified during the self-study. It is also the purpose of the site visit to confirm
that the educational program meets all of the requirements that are expected of an
accredited program.
The purpose of the site visit is to validate the Self-Study Report and evaluate the
program’s compliance with the Standards and Guidelines. The site visit evaluation
includes a review of both the didactic and clinical aspects of the program including visits
to both on-campus and off-campus clinical experience sites and to evaluate the
correlation between the didactic and clinical aspects of the program. The number of offcampus clinical sites and specific facilities to be visited is determined by the CAATE site
visitors.
A. After the CAATE office receives the self-study submission notification and related materials
via email, and the payment of the self-study and site visit fee, the following steps occur:
1.
The CAATE office assigns a site visit team to the residency program. The site visit
team will consist of a site visit chair, a site visit member, and a site visit reader.
2.
Prior to the site visit, the Program Director of the residency program is notified, via
email, of the names and affiliations of the individuals assigned to the team. At that
time, if the Program Director perceives a conflict of interest, the Program Director may
request replacement of any member of the site visit team. The CAATE decreases the
likelihood of conflicts of interest by having the site visitors sign a conflict of interest
form in advance of the selection.
3.
Once program approval of the site visitors is received by the CAATE office, the site
visitors are notified of their site visit assignment.
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
24
4.
5.
6.
7.
8.
The site visit team is given access to the documents.
The site visitors review program documents/self-study.
The Site Visit Team will do a preliminary review of the program’s self-study to
determine if the program has included the required information in the self-study and
that there is sufficient compliance to be able to move forward with a site visit.
The site visit chair makes contact with the program following the preliminary review
of the self-study. If it is determined that the program is ready for a site visit, the Site
Visit Chair will contact the Program Director to begin planning the site visit. If there
are deficiencies in the self-study, the Site-Visit Chair will contact the Program Director
to discuss the deficiencies and a plan and timeline for correction prior to scheduling any
site visit. All contact between the program and the site visit team should occur through
the site visit chair.
If additional materials are deemed necessary, the site visit chair will notify the Program
Director that additional materials are needed. The requested materials will be submitted
via email within a timeframe that is mutually agreeable between the Program Director
and the site visit team. These additional materials will then be reviewed by the site visit
team. The request from the site visit chair for supplemental materials will be made no
later than 30 days prior to the site visit. The site visit chair may request these materials
be made available in advance of the site visit team’s arrival or be made available onsite.
B. Site Visit Procedures
1. Application for a site visit for initial programs can only occur following the complete
implementation of the Standards.
2. Site visits must not be scheduled during periods in which any part of the program is
inactive or key personnel are not available (e.g., vacation periods).
3. The site visit chair establishes a timetable for the site visit during the initial contacts
with the Program Director.
4. The site visit will occur between October 1 and February 15. Exceptions to these dates
must be approved by the CAATE office.
5. All expenses officially connected to the site visit team including travel, lodging, meals,
and site visitor honoraria are paid by the CAATE from the accreditation fees that were
submitted to the CAATE. The program should pay no additional expenses for the site
visit.
6. The site visit chair works with the Program Director to finalize the arrangements of the
site visit (e.g., visitation dates, travel schedules, ground transportation, lodging
reservations). A minimum of three days must be allotted for the site visit in order for a
thorough and productive evaluation. A typical site visit schedule is presented below.
7. The Program Director must prepare a written site visit itinerary and interview schedule
in consultation with the site visit chair. The itinerary must be finalized at least two
weeks prior to the scheduled visitation date. Questions pertaining to preparation of the
itinerary and interview schedule must be directed to the site visit chair.
C. Itinerary and Interview Schedule
1. The site visit itinerary must include:
a. Interview sessions with names, credentials and titles of all personnel
b. Visitation of facilities
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
25
2.
3.
4.
c. Site visit team evaluation meetings
d. Exit conference
The site visit schedule should be developed to span across three days. A typical site
visit begins in the afternoon of the arrival day and concludes by noon three days later
(e.g. Sunday through Wednesday or Tuesday through Friday). Spanning the visit across
three days facilitates interaction with all individuals associated with the program and
allows time for reflection by the site visit team.
It is suggested that the site visitors have a dedicated room for interviews, individual
writing, and work. Meals should be scheduled so the site visit team can discuss
information privately.
Interviews will vary in length according to the personnel involved. Schedule additional
travel time between meeting rooms and facilities if some sessions must be scheduled at
other locations. The Program Director, faculty, preceptors, and current residents must
be scheduled during the first full day of interviews. The following schedule of
personnel and meeting times should be followed closely in the development of the site
visit itinerary. Flexibility in scheduling of interviews is permitted according to the
availability of personnel, with the exception of the Program Director, who must be
scheduled first.
Tentative Site Visit Agenda
Arrival Day – Preliminary Conference / Dinner
The SV team meets with the Program Director (PD) and Clinical Education Coordinator,
if applicable.
1) Review the schedule with PD for any possible last minute changes scheduled.
2) This meeting can also provide an opportunity for the PD and the SVers to get acquainted on an
informal basis prior to the actual visit taking place. It can also be used to provide the visitors with an
opportunity to obtain a more complete understanding of the curriculum and the program objectives,
philosophies, course objectives, operational procedures, resident selection criteria (if used), resident
evaluation protocols, enrollment, resident attrition rates, processes for monitoring progress in
development of resident knowledge and skills, success of program graduates, etc.
Day #1 of Site Visit
8:00 am
SV
8:15 am
10:15 am
10:30 am
11:15 am
12:30 pm
1:30 pm
3:30 pm
4:15 pm
5:15 pm
Site visit team meets with the PD and appropriate
administration to welcome everyone, review the accreditation
process and its purpose and value, and the roles and functions of
the review committee
Program Director initial conference meeting
Break
Facility visits to classrooms, laboratories, health center, online
library access, or other applicable facilities
Preceptors
Working lunch – Site Visit Team
Resident interviews
Pre-Admit Resident interviews (if applicable)
Athletic training residency clinical facilities tour
Medical Director
Pursuing and Maintaining Accreditation of Post-Professional Residency Programs
26
6:00 pm
Day #2 of Site Visit
8:00 am
9:00 am
10:00 am
11:15 am
11:45 am
1:00 pm
1:35 pm
2:10 pm
2:45 pm
5:00 pm
6:00 pm
Day #3 – Site Visit
8:00 am
9:00 am
11:00 am
11:30 am
12:00 pm
Site Visit Team dinner
Program Director Conference
Assessment Office (if applicable) and review all on-site
materials
Program faculty
Clerical staff
Working lunch – Site Visit Team
Department Chair meeting if applicable
Dean meeting if applicable
President/CEO Meeting
Visit Affiliated Sites – may interview Preceptors at these sites
(SVers can split up to complete these visits)
Program Director conference – request additional information
and/or to clarify findings
Site Visit Team dinner
Program Director conference – request for additional
information and/or to clarify findings
Site Visit Team Executive Session to reach consensus on
potential NCs and recommendations
Program Director Exit Summary
Exit Conference to University Administration, Program
Director, etc
Lunch/Airport (Site Visit Team completes and edits the report)
D. Visitation of Facilities
1. Allot ample time for visiting facilities used by the program.
2. The number of clinical sites and which clinical sites are visited will be determined by
the site visit team in consultation with the Program Director. Site visitors may need to
split up and go to separate clinical sites for efficient use of time.
E.
Site Visit Team Meeting
1. The site visit team will schedule time to reach consensus between the site visitors on
potential non-compliances and recommendations prior to the final meeting with the Program
Director and the exit conference.
F. Final meeting with Program Director
1. This final 30-minute meeting is held before the exit conference.
2. This meeting is scheduled to inform the Program Director of the site visit team’s
preliminary findings and allow time for questions from the Program Director.
G. Exit Conference
1. A 30-minute exit conference must be scheduled after the final meeting with the
Program Director. The site visit team will discuss its preliminary report.
2. The exit conference is designed to present the site visit team’s preliminary findings
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3.
related to compliance with the Standards. The site visit team will provide a description
of programmatic strengths, non-compliance(s) with the Standards, and
recommendations. The site visit team does not make accreditation recommendations,
nor should they be asked to provide specifics as to how the institution may rectify noncompliances. Guidelines for the methods needed to rectify non-compliant areas will be
provided to the institution by the CAATE.
Other appropriate personnel as determined by the sponsoring institution may be invited
to attend the exit conference.
H. Site Visit Report
1. Within one week following the site visit, the site visit team will complete a history of
the program, identify program non-compliances, list program strengths, and
recommendations. An additional week will be required for proof reading the report.
2. The CAATE office assigns a Review Team to the program’s report and alerts the teams
to the report’s availability.
3. The assigned Review Teams will review the report for content and clarity with the site
visit chair and the document will be revised as needed.
4. The Review Team will provide responses to non-compliances, if applicable, indicating
what evidence must be submitted for the program to come into compliance.
5. The Site Visit Report is made available to the appropriate academic administrators of
the sponsoring institution and the Program Director within 4-8 weeks of the site visit.
Program administrators may then share this report with other institutional personnel as
necessary. The report defines any area of the Standards for which the site visit team
found the program to be deficient at the time of the site visit. Each section of
deficiencies corresponds to a section of the Standards and is defined by the associated
Standards number.
6. The final Site Visit Report will be emailed to the program.
7. If there are numerous citations, the program going through an initial accreditation
process may choose to withdraw its application at that time and re-apply at a later time.
This withdrawal and reapplication would require the submission of a new self-study,
application fee, and result in another site visit which will be conducted by a new site
visit team. Should a continuing program choose this option, it would be placed on
Probation until such time that the next site visit would occur or a one year interval,
whichever event occurs first, and after which action for involuntary withdrawal of
accreditation would occur.
VI.
Site Visit Report Response (Rejoinder)
A response to the Site Visit Report (Rejoinder) is required by all programs, regardless of the
number of citations, and must include the signature of the President/Chief Executive Officer of
the sponsoring organization and the Program Director. Program personnel will have 90 days
from the date of receipt of the Site Visit Report to submit their Rejoinder via email to the
CAATE. The sponsoring institution’s response to the Site Visit Report should address any
factual errors, misinterpretations, clarifications, recommendations, and/or deficiencies and
address any non-compliances. If no deficiencies are cited, and/or the Site Visit Report is
accepted by the institution “as is,” receipt of the Site Visit Report must be acknowledged through
e-Accreditation and include the electronic “signature” of President/CEO of the sponsoring
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organization and Program Director. As part of the Rejoinder process, the organization officials
will be solicited for their feedback on the quality and professionalism of the site visit team, as
well as the site visit process itself. These evaluations do not affect the outcome of the
accreditation decision in any manner and are not seen by the site visitors or the Commission until
after accreditation decisions are made.
A. Review of Program Rejoinder
Implicit in the recognition of CAATE accreditation is the requirement that the CAATE take adequate and
appropriate measures to ensure that the programs it evaluates have demonstrated compliance with each of
the Standards.
The Site Visit Report and the Program’s Rejoinder are evaluated by the CAATE at regularly scheduled
semi-annual meetings held in late winter/early spring and in summer/fall. A recommendation for
appropriate accreditation action is based upon the Program’s Rejoinder. The sponsoring organization and
program are notified of the CAATE accreditation action by electronic letter from the CAATE office. In
the case of initial accreditation, the program will be notified, via email, of either withholding, tabling a
decision, or the award of initial accreditation.
When determining a recommendation for accreditation, the CAATE considers the Site Visit Report, the
Program’s Rejoinder to the Site Visit Report, and all documentation supporting the Rejoinder. The
Program Rejoinder must demonstrate, at the time of Program Rejoinder Review, implementation of
actions that demonstrate compliance with the Standards. Plans not yet put into practice will remain in
non-compliance until there is sufficient evidence to document that the plans have been implemented.
Assurance of development may be demonstrated to the CAATE through provision of necessary
documents, e.g. resident policies, course outlines, clinical experience schedules, and completed evaluation
instruments. Submission of such documents is a comparatively easy and effective way of demonstrating
compliance with some Standards. However, there are components of the Standards that require a site
visit evaluation and interviews with appropriate individuals involved in the program.
Accreditation Actions
The CAATE decision related to an accreditation action is communicated by CAATE via an email that
identifies the length of accreditation and also cites any remaining areas of non-compliance with the
Standards. A Progress Report will be requested to address any outstanding non-compliances.
Accreditation Award
CAATE determines the accreditation status of the program at a regularly scheduled meeting, and notifies
the sponsoring institution and program of its action, via email electronically, promptly after each meeting.
Timetable for the Accreditation Process:
1.
The Self-Study and the application fee submitted to the CAATE.
Submission date is July 1st. Self-studies must be received by the
CAATE via on or before July 1st. No Self-study reports or
additional materials will be accepted after the deadlines without
penalty. For clarification of these penalties, please see the CAATE
Policy & Procedures Manual.
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2.
Site visits are normally conducted within four to eight months of the
receipt of the self-study by the CAATE, except upon written specific
agreement of the program or in instances for which the CAATE has
documented concerns for compliance with the Standards or self-study
format. A window of dates will be determined and the site visit must
occur during that time frame.
3.
The Site Visit Report is returned to the program approximately 4 – 8
weeks after the site visit.
4.
Program personnel will have 90 days to submit their Rejoinder
(responses to requested materials) to the CAATE.
5.
Programs are considered by the CAATE at a scheduled semi-annual
meeting (i.e. late winter/early spring and summer/fall), which may be
from two to eight months after the CAATE receives the Rejoinder. The
CAATE also conducts conference calls as warranted.
The normal accreditation process (from submission of self-study through CAATE action) takes from a
minimum of 12 months to as much as 24 months depending upon when various steps are reached on the
above mentioned timetable.
The accreditation process timetable may be lengthened due to institutional/program problems, extenuating
circumstances, failure to observe deadlines, submission of incomplete or inadequate application or selfstudy or failure to establish the ability to comply with the Standards. The CAATE may table action on
programs that require additional materials to clarify their institutional response. The CAATE will make
every effort to assist the program in expediting the process; however, the responsibility for achieving
accreditation through CAATE rests with the program.
Other accreditation categories, probation, withholding or withdrawing accreditation, and voluntary
withdrawal of accreditation are defined at http://www.caate.net/definitions-of-accreditation-actions/,
More information on the above actions may be found in the CAATE Policy and Procedure Manual
available at http://caate.occutrain.net/wp-content/uploads/2014/01/CAATE-POLICIES-PROCEDURESNOVEMBER-2013.pdf
Maintaining and administering accreditation requires numerous responsibilities such as completing a
CAATE Annual Report, notification of changes in Program Directors, clinical staff, and administrators,
initial placement of graduates, and other functions prescribed by the CAATE. Failure to notify the
CAATE of change in personnel, especially the Program Director, within 30 days may result in
administrative probation or ultimately in probation.
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