American Academy of Orthopaedic Manual Physical Therapists Fellow Renewal Application

American Academy of Orthopaedic Manual Physical Therapists Fellow Renewal Application Thank you for your contribution over the last ten years as a Fellow of AAOMPT. The following overview is provided in an effort to familiarize you with the renewal process. Further details regarding each requirement for renewal are included in the appropriate section of the application. The designation of Fellow as described in the original AAOMPT bylaws is both a membership classification and a professional credential (FAAOMPT). Fellowship designations are awarded for a ten-year term. The ten year term expires every tenth anniversary of the date of completion of your original fellowship or residency program or the date of the AAOMPT challenge/fellowship examination. The expiration date of the fellowship designation is usually indicated on your AAOMPT Fellow certificate. Fellows may submit an application for renewal at any time before the expiration of the ten year term. The deadline for receipt of applications for fellow renewal is July 15 of each year. To maintain continuous Fellow status, Fellows must submit a renewal application by the July 15 deadline prior to the expiration of the ten year term. The Standards Committee reviews applications for renewal after July 15. Renewing Fellows can expect to be notified of the status of their application by early September. Renewing Fellows will be recognized at the subsequent Fellow recognition ceremony at the AAOMPT Annual Conference in October. Fellows who have not completed the requirements, or who are asked to submit additional clarifying information will be given a 1 year extension of their Fellow status providing they submit an application for renewal prior to the expiration of the ten year term. Fellows who have not completed the requirements for renewal at the expiration of their ten year term should submit an application detailing their progress towards meeting the criteria to date. The Standards Committee will notify fellows of any outstanding requirements, or requests for additional information in early September. Fellows who are 62 years and older at the time of renewal, and who have been a member in good standing with AAOMPT for a minimum of 10 years, may apply to become a Life Fellow. All of the activities listed on the renewal application must be post-professional activities and must have been completed after the initial date of FAAOMPT eligibility or in the case of a fellow who has previously renewed, after the date of the previous renewal. AAOMPT Fellow Renewal Application, Rev. 01/15 Page 1

American Academy of Orthopaedic Manual Physical Therapists Standards Committee 8550 United Plaza Boulevard, Suite 1001 Baton Rouge, LA 70809 225-360-3124 office@aaompt.org A. General Information Name: Last: Title: First: Middle: Designations PT, Today s Date: Address: Street: City: (residence) State: Zip: Address: Street: City: (business) State: Zip: Contact info: Business Phone: Home Phone: Email Address: Date of Birth MM-DD-YYYY AAOMPT Fellow Number: Effective Date: Fellow Member: Y/N Annual Dues Paid: Y/N APTA Member Number: Ortho Section Member: Y/N ABPTS Clinical Specialist: Y/N Certifications Recertification Years: Practice Info Title: Type of Practice: Years Experience: As practicing PT: As Ortho/OMPT: B. Manual Physical Therapy (OMPT) Fellowship Education Training Name of Institution/Program: Graduation Date: MM-DD-YYYY C. AAOMPT Challenge Process Date of completion of Challenge Process: MM-DD-YYYY D. License Verification list the states where you have a current physical therapy license, the numbers and the expiration dates. Information will be reviewed at www.fstbpt.org Your Name Last: First: Middle: PT License # State: Exp. Date: PT License # State: Exp. Date: PT License # State: Exp. Date: AAOMPT Fellow Renewal Application, Rev. 01/15 Page 2

E. Affidavit: Verification of Truth and Accuracy I,, hereby affirm that I have completed all application documents accurately and truthfully. I further understand that any incorrect information or omission of information may result in my not being granted Fellow status in the AAOMPT. I further understand that this status as Fellow is valid for a prescribed period of time, whereupon an additional renewal of Fellow status is required. Signature of Applicant Date Notary Public Name AAOMPT Fellow Renewal Application, Rev. 01/15 Page 3

F. PORTFOLIO for 10-year Fellow renewal 1. Fellows must document professional development activities that reflect the Description of Advanced Specialty Practice (DASP). These five activities are: a. Patient care b. Education development c. Teaching d. Scholarly activity e. Professional service 2. Fellows must completely meet all requirements in at least 4 of the 5 criteria. 3. The following pages contain one blank copy of each category of the Portfolio on which you should document your professional activities. 4. At the top of each page is an example of how to record the activity. Please record your activities in the same manner. 5. Record each activity in only one category. 6. Applicants are not required to submit original documentation of activities with this application form; however, Fellows must be able to provide documentation for the activities listed. Documentation such as transcripts, course certificates, course content outlines, research abstracts, article reprints, and letters of appreciation for volunteer work, or the like may be requested in the case of random audit. 7. Please type your information directly on this word document and then print it out. AAOMPT Fellow Renewal Application, Rev. 01/15 Page 4

PORTFOLIO CATEGORIES FELLOW RENEWAL PATIENT CARE Support Statement: In the spirit of Manual Therapy being a 'hands-on' subspecialty within Orthopedic Specialization, the AAOMPT requires that Fellows continue to improve their manual and clinical skill, clinical pattern recognition and critical thinking to maintain the highest level of recognized clinical practice through direct patient care. Objectives: Continued professional development through patient care Continued use of clinical reasoning skills in the management of physical impairments Opportunity to practice the information gained from the educational requirements Opportunity to use evidence-based medicine Opportunity to develop clinical research questions Develop best clinical teaching information based on actual patient examples and case studies Criteria: 2000 hours of direct patient care is required. The patient care hours may be pro bono hours or paid employment. The Fellow must be the primary treating clinician having performed some or all of the following: the initial evaluation, follow up visits and discharge planning. Please include the name and location of the facility, the dates of patient care and the hours. Example: Ace Physical Therapy, Chico CA 2001-2004, 4000 hours. If you are not sure of the exact hours, you may estimate them as follows: 40 hours/wk x 50 wks/yr x 2 years = 4000hrs. The following examples do not meet the criteria: Clinical supervision and / or mentoring of a physical therapy student or post-professional residency or fellowship student Management of a clinical site that does not require direct patient care Analysis and reflection of patient interaction with a peer or student Administrative and marketing activities Review of case studies AAOMPT Fellow Renewal Application, Rev. 01/15 Page 5

Criteria Patient care 2000 hours direct or indirect patient care over 10 years Cumulative Hours Total AAOMPT Fellow Renewal Application, Rev. 01/15 Page 6

EDUCATIONAL DEVELOPMENT Support Statement: In the spirit of the lifetime learner, the AAOMPT requires that Fellows continue to improve their clinical skill, critical thinking and knowledge base to maintain the highest level of recognized clinical practice. Objectives: Continued profession development through education Enhance, continued development - knowledge base of the evidence Enhance in critical thinking, decision making and treatment planning Enhance hands on skill for patient care Enhance knowledge for patient education, health, exercise and ergonomics Maintain exposure to current trends and advances in patient care Research: Methodology, design and/or statistics Reimbursement Practice Management Legal: HIPAA, documentation, safety Criteria: 300 contact hours or 30 CEU s or 30 academic credits in OMPT or related sciences are required. You may list courses using either contact hours or CEU s, but not both. You must include the total contact hours or CEU s at the end of the list. Hours may be converted using the following formulas: a) One CEU is equal to 10 contact hours, b) One semester hour academic credit = 15 contact hours = 1.5 CEUs, c) One quarter hour academic credit= 10 contact hours = 1.0 CEU. Examples of educational development activities that meet the requirement include: Continuing education seminar with a certificate of completion Attendance at professional symposia and conferences Post-professional degree studies Structured home study with a certificate of completion On-line courses with a certificate of completion Please list the title and presenting organization, dates, of the courses as well as the CEU s or contact hours, for example: Management of Whiplash Injuries, CAPTA Annual Conference, October 9-12, 2007 (24 contact hours) AAOMPT Fellow Renewal Application, Rev. 01/15 Page 7

Criteria Educational Development: 300 contact hours or 30 CEUs or 30 academic credits over 10 years. Cumulative Hours Total AAOMPT Fellow Renewal Application, Rev. 01/15 Page 8

TEACHING Support Statement: Fellows are considered experts in OMPT, and therefore, are expected to pass on this expertise through teaching physical therapy students, residents in training, fellows in training, and/or other physical therapists. Teaching requires integration of knowledge and expertise and allows the Fellow to demonstrate professional growth and expansion of knowledge base in the topic to be presented and in the process of teaching. Objective: Fellows must demonstrate competence in teaching methods in their areas of expertise. Criteria: 300 contact hours over 10 years are required. Ways to demonstrate meeting the requirement include: providing classroom, on-line, or clinical instruction for physical therapy students, residents in training, fellows in training, and other physical therapists through both oneto-one mentoring, facilitation of group learning activities, or more traditional lecture format teaching experiences. Examples include: Providing a continuing education course for physical therapists Clinical instructor for an entry-level physical therapist student In-service training for physical therapy staff On-line instructor for a course in a transitional DPT program Clinical mentoring in a Residency/Fellowship program Teaching a course for a professional physical therapist program List clinical teaching hours as follows: CI for 3 physical therapy students 240 contact hours each 2007 to 2009-720 hours List continuing education courses as follows: Instructor, Manual Therapy Techniques for the Hip, PT Seminars R Us, October 9-12 2007 24 contact hours List university, fellowship, or residency teaching as follows: University of the Delta, Clinical kinesiology, fall semester 2007 through 2011, 30 contact hours each = 150 hours. AAOMPT Fellow Renewal Application, Rev. 01/15 Page 9

Criteria Teaching: 300 contact hours over 10 years Cumulative Hours Total AAOMPT Fellow Renewal Application, Rev. 01/15 Page 10

SCHOLARLY ACTIVITY Support Statement: Scholarly activities may be research or non-research related. The essential component of scholarly work is that it goes through a critical review or editorial process for scientific merit and provides references. Though typically directed towards an audience of professional peers, it may also be directed towards an audience of patients or clients. Full time clinicians may find nonresearch oriented activities more suited to their environment, while those in an academic setting may find formal research activities more suited to their environment. Objective: To increase the availability of credible evidence related to OMPT in all categories of the evidence hierarchy, and to demonstrate/illustrate the integration best evidence in clinical practice. Criteria: Three OMPT related scholarly activities over the last 10 years are required. This is approximately one activity every three years but can be done anytime. The 3 activities may be all one type, or any combination. Non-research oriented scholarly activities: Submitting Clinical Pearls, Clinically Appraised Topics (CATs) or book reviews in Articulations; clinical reasoning cases with references submitted online to a peer accessed/professional website (e.g. APTA /AAOMPT/Ortho Section website, fellowship/residency website); extracting articles for APTA s Hooked on Evidence; professional writing submitted to non-peer reviewed journals or magazines; expert testimony or external consulting that involves submission of formal documents for public record and is accessible to a peer audience; scholarly products produced as part of task forces or committees that provides an author list; service as a consultant for a hospital, insurance company, Provider Network, local/state/federal agencies where the Fellow contributes scholarly material available to a peer and/or public audience; designing curriculum for courses such as a weekend seminar on an OMPT topic; designing/developing an online module related to OMPT for a Fellowship/ Residency/University program if referenced accordingly; participating in a panel discussion that is heard publically at a local hospital, radio, television, webinar or podcast. Examples are listed below: Mankinen J. Active Radial Nerve Glide with Trunk Rotation Component AAOMPT Articulation Clinical Pearl. Submitted for On-Line Publication March 2011. Molina P. Use of a Stick Ball for Self Mobilization of the First Rib Clinical Pearl in Orange County District APTA Newsletter March 2005. Gill, NW. DOD/VA Low Back Pain Clinical Practice Guidelines Taskforce. Neurological Examination Videos. https://www.qmo.amedd.army.mil/lbp/video/lbp.html. Nov 2009. AAOMPT Fellow Renewal Application, Rev. 01/15 Page 11

Article extraction on APTA Hooked on Evidence. Name of the Article. Date extraction was completed. Panel Discussion Participant. Name of Panel Discussion. At Name of Conference. or available at https://podcast website. Research oriented scholarly activities: Poster, platform, and invited speaker presentations at formal professional conferences or events; professional writing published in peer reviewed journals or other formal professional publications; serving as an editor for formal professional publications; serving as a reviewer of manuscripts or books for formal professional publishing institutions. For professional presentations include the type of presentation (poster, platform, invited speaker), the title of the formal professional event at which it was given, the name(s) of the presenters, the title of the presentation, and the date of the presentation. Examples are listed below: Poster Presentation, 2009 California Physical Therapy Association Annual Conference; T. Little, J. Smith Avascular Necrosis in Individuals With Talus Fractures: Demonstration of Functional Anatomy in a Human Cadaver Model October, 2009 Invited speaker, Physical Therapy Management of LBP. Western Region Occupational Medicine Physician Meeting, Las Vegas NV 2008 For professional writing include the name of the author(s), the title of the article, chapter, or book; the name of the publication in which it was published, or in the case of a book the name of the publishing house; the year in which it was published, and the volume and page numbers of the article if relevant. An example is listed below: Little T, Lazaro R. "Physiotherapists' perceptions and use of medical imaging information in practice" Physiotherapy Research International, 2006;11(1):14-23. For Editing or Reviewing books and/or manuscripts include the type of activity (editor or reviewer), the name of the manuscript or book, the name of the journal or publishing house for which the service was performed, and the date the review was conducted. An example is listed below: Manuscript reviewer, "Physiotherapists' perceptions and use of medical imaging information in practice." Physiotherapy Research International, 2005. AAOMPT Fellow Renewal Application, Rev. 01/15 Page 12

Criteria Scholarly Activity: 3 OMPT related activities Total AAOMPT Fellow Renewal Application, Rev. 01/15 Page 13

PROFESSIONAL SERVICE (to the profession or to the public) Support Statement: Fellows are considered experts and leaders in OMPT and the communities they serve, and therefore, are expected to give back to their profession and community/public by providing service that contributes to the greater good of the profession and the public. Objective: Fellows must demonstrate a high level of commitment to the profession by providing professional service to the professional and to the public. Criteria: Five examples of professional service are required in which the Fellow is representing the profession and contributing to the profession or the community without being paid for this service. One year of service to a professional or community organization is considered one event. Ways to demonstrate meeting the requirement include: Professional service to the public includes providing pro-bono services to patients, providing professional services at community events such as health fairs, providing professional services to sports teams or schools or other organizations. Service to the profession includes serving on APTA, AAOMPT or other professional committees, or as an elected representative, or providing other formal professional services for which the Fellow is not paid to the professional community. Attendance at APTA or AAOMPT meetings in and of itself is not considered professional service. Examples include: Serving on an APTA or AAOMPT committee/subcommittee for one year Serving as an elected official of a professional association (national/state/district) Serving on the board of directors for a non-for-profit organization Providing a free professional service for a community event such as post-race massage/stretching/consultation for a 10k race put on by a non-for-profit organization Providing a free service for a community event screening for osteoporosis and falls risk Serving on Texas Physical Therapy Association taskforce for CEU approval process Serving as a member of the state PT/OT licensing board Participation as a PT x 1 year in Project Access in the Anchorage Alaska for uninsured persons Volunteer PT for Westside Wizards youth wrestling team for winter season ACL tear prevention clinic for Varsity Soccer team pro bono (4 hours) List service to the profession as, served as a member of the AAOMPT nominations committee from 2010 2012. Each year counts as one activity. List service to the public/community as, provided free physical therapy coverage and post-race consultation for runners for the Chicago marathon in October 12, 2011 AAOMPT Fellow Renewal Application, Rev. 01/15 Page 14

Professional Service: 5 activities Criteria Total AAOMPT Fellow Renewal Application, Rev. 01/15 Page 15

CHECK LIST FOR FELLOW RENEWAL APPLICATION Information is typed directly on the word document and printed out, or printed clearly. All sections are completed One of the following has been copied and is attached o The certificate awarded to you upon OMPT Fellowship (original residency) graduation OR o The certificate awarded upon satisfactorily passing the challenge process. The Affidavit page has been completed and signed by a notary including their seal A check made out to AAOMPT is enclosed or credit card information has been included below. Payment Information: $250.00 check made payable to AAOMPT VISA/MasterCard/AMEX (circle one) Card number: Expiration Date: Billing Address: City: State: Zip: Cardholders Name: Cardholder s Signature: Date: Please submit with all required information to: American Academy of Orthopaedic Manual Physical Therapists Standards Committee 8550 United Plaza Boulevard, Suite 1001 Baton Rouge, LA 70809 office@aaompt.org AAOMPT Fellow Renewal Application, Rev. 01/15 Page 16