APPLICATION FOR A-STEP PROVIDER

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1 APPLICATION FOR A-STEP PROVIDER November 17, 2014 Page 1

2 A-STEP FORM I: GENERAL APPLICANT INFORMATION A. Please provide the name, address and additional information for the applicant A-STEP Provider. NEW ACCREDITATION: REACCREDITATION: Name of the A-STEP Program: Provider Program Website Address: A-STEP Program Location Address: City: Phone: Does the program have more than four students? If yes, does the program have a classroom for didactic instruction? Does the program provide an online portion? If an online portion is provided, please answer the 5 questions in the next field. (Standard 26) State: Zip: Fax: Does the program have access to polysomnographic recording and treatment equipment used routinely by sleep technologists? 1. Does the online portion make up more 30% of the program? 2. Are hands-on learning and practical experiences dealt with exclusively through the online portion? 3. Is the online portion suitable for entry level students? 4. Is the quality and organization material appropriate for self-learning? 5. Are provisions in place for users to have timely access to faculty for questions? B. Please provide the name, address and accreditation number for the affiliated AASM fully accredited sleep disorder center. Affiliated AASM Accredited Center Name: Affiliated AASM Accredited Center Accreditation Number: Affiliated AASM Accredited Center Address: City: State: Zip: C. Please list contact information for the A-STEP s primary contact. All communication concerning accreditation will be through this person via . Primary Contact Person: Phone: November 17, 2014 Page 2

3 A-STEP FORM II: STAFF LIST Please complete and submit this list including information for the following staff. Name Position/Title Credentials Total Hours of Instruction (hours/week) Program Director Clinical Director Technical Director November 17, 2014 Page 3

4 A-STEP FORM III: ATTESTATION We, the undersigned, certify that the statements herein are true and complete to the best of our knowledge and accept responsibility for the continued existence and support of this facility as a provider of the highest possible level of technician education. We, the undersigned agree to report changes in resources, curriculum or key personnel to the AASM within 90 days when they impact compliance with these standards. A-STEP PROGRAM DIRECTOR CLINICAL DIRECTOR (BOARD-CERTIFIED IN SLEEP MEDICINE BY THE AMERICAN BOARD OF SLEEP MEDICINE OR BY A BOARD OF THE AMERICAN BOARD OF MEDICAL SPECIALTIES) TECHNICAL DIRECTOR (RST or RPSGT) November 17, 2014 Page 4

5 Supplemental Documents List Below are the required documents to be submitted with the A-STEP Accreditation Application. This is a tool to be used only for your reference. Details for specific sections are noted by the standard number below: 1. Syllabus 2. Library List to include at minimum copies of: a. International Classification of Sleep Disorders, Third Edition b. Clinical Practice Parameters of the American Academy of Sleep Medicine c. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specification d. CPR/AED for the Professional Rescuer by the American Red Cross. 3. For a new application: Midpoint Evaluation Tool. For a reaccreditation application: Midpoint Evaluation Tool and most recent Summary Results Report. (Standard 27) 4. For a new application: Policy and Tools. For a reaccreditation application: Policy, tools and most recent summary results report. (Standard 28 and 29) 5. Minimum Requirements Policy for students 6. Fair Practices Policy and Procedures 7. If program includes an online portion: Access information for potential reviewers to confirm online content. November 17, 2014 Page 5

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