American Board of Physical Therapy Residency and Fellowship Education
Credentialing Services Committee Application
The American Board of Physical Therapy Residency and Fellowship Education is seeking a cadre
of members with diverse clinical expertise to serve on the Credentialing Services Committee.
If you are interested in submitting your name to the applicant pool for the Credentialing Services
Committee, please complete the following information. Applications are due to APTA Staff by
October 7, 2012. Appointments to the Committee by the Credentialing Services Council will
occur on October 29, 2012. Notification regarding appointments will be sent by November 15,
2012.
*If appointed, you MUST be available for training on Monday, March 11, 2013 from 8:00am to
3:00pm at ATPA Headquarters in Alexandria, VA. All travel expenses will be paid by APTA for
this meeting.
Name: ______________________________________ APTA Member # __________________
Credentials (eg, PT, DPT, OCS):__________________________________________________
Address:_____________________________________________________________________
Phone: ___________________________ E-mail:_____________________________________
Current Position/Job Title: ______________________________________________________
Please indicate number of years of:
Clinical Experience as a licensed physical therapist___________
Experience as a Clinical Instructor
___________
Experience as a Residency/Fellowship Mentor
___________
Experience in other areas of residency or fellowship education
___________
Briefly describe relevant experience in clinical and didactic education, including
experience with residency/fellowship education:
Briefly describe relevant experience in educational program evaluation/assessment:
Briefly describe any roles that you may have had related to regulation of the profession
(FSBPT, JCAHO, etc..):
ABPTRFE Credentialing Services Committee Application
Please also submit a one-two page resume/curriculum vitae highlighting activities
pertinent to this position.
Committee Information and Responsibilities:
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Credentialing Services Committee members review written applications and conduct site
visits for residency and fellowship programs seeking credentialing from APTA.
Committee members are selected for a term of at least two years, and agree to complete
a two-part training.
Part One of the training will be completed online and Part Two requires new members to
complete training onsite at APTA.
Members agree to be available for at least three application reviews and three site visits
per year, and agree to stay current in residency/fellowship application evaluation
procedures.
The minimum time requirement for a Committee member to complete an application
review varies depending on the complexity of the program application, generally requiring
3-4 hours for the paper review and one to two days to conduct the site visit.
Qualified candidates have obtained ABPTS specialist certification and/or AAOMPT fellow
status, demonstrated clinical expertise, experience in clinical teaching, and the ability to
provide objective evaluation.
*If appointed, you MUST be available for training
on Monday, March 11, 2013 from 8:00am to
3:00pm at APTA Headquarters in Alexandria,
Virginia. All travel expenses will be paid by APTA.
I understand that the Board will select Committee members based on the needs of the Committee
and the qualifications of the individual. I agree to serve as a Credentialing Services Committee
member for a minimum of two (2) years and will consent to complete at least three application
evaluations/year including the site visit. I also agree to participate in annual training to maintain
currency.
Signature_____________________________________________________ Date ____________
Please return completed application to Stephanie Hernandez at
stephaniehernandez@apta.org. Information regarding the online Part One training
session will be provided upon appointment to the Committee.
ABPTRFE Credentialing Services Committee Application