Provisional_restrictions_applicationpkg_140930.pdf

Application Package

Provisional Practice With Restrictions

September 2014

©2014 College of Physiotherapists of Ontario

Provisional Practice with Restrictions Application Package Provisional Practice with Restrictions allows an individual the opportunity to practice after the first unsuccessful completion of the clinical component of the Physiotherapy Competency Examination (PCE). This requires increased levels of supervision and increased reporting to the College to ensure public protection. This package includes an information sheet, an application guide and form and the Plan and Agreement. Section 1

Provisional Practice Information for Residents and Supervisors

page 3

Section 2

Application for Registration Guide

page 7

Section 3

Application Form (to be completed by Applicant)

page 13

Section 4

Plan and Agreement (to be completed by Applicant and Supervisor[s])

page 25

For questions about registration and applying to the College, please contact: Entry to Practice team 416-591-3828 ext. 222 or 1-800-583-5885 ext. 222 [email protected]

College of Physiotherapists of Ontario 375 University Avenue, Suite 901, Toronto, ON M5G 2J5 Tel: 416-591-3828 or 1-800-583-5885 | Fax: 416-591-3834 | www.collegept.org

Provisional Practice with Restrictions Application Information

Page 2

Provisional Practice with Restrictions Information for Residents and Supervisors Provisional Practice with Restrictions applies to Physiotherapy Residents who were unsuccessful in their first attempt of the clinical component of the Physiotherapy Competency Exam (PCE), and may now continue to practice under full and direct supervision. They must be registered in the next upcoming clinical component of the exam. If the resident is unsuccessful at a second attempt at the clinical component of the PCE, the Resident must stop practicing physiotherapy on or before the expiry date as shown on his or her certificate. A Provisional Practice with Restrictions certificate will not be re-issued. If the Resident is successful at the second attempt at the clinical component of the PCE, the individual must apply for an Independent Practice certificate before the expiry date listed on their certificate of registration, to continue to practice. An individual who is granted a Provisional Practice Certificate with Restrictions can practice as a Physiotherapy Resident provided he or she receives full and direct onsite supervision from a physiotherapist holding an Independent Practice Certificate. The Resident is issued a registration number entitling him or her to perform controlled acts if competent and rostered to do so, bill for physiotherapy services, and complete client records. Physiotherapy Residents are accountable to the College for their actions. To qualify for a certificate authorizing Provisional Practice with Restrictions, the Resident must •

successfully complete a degree in physiotherapy/physical therapy from a university in Canada or have gained an academic qualification from outside Canada that is considered by the Canadian Alliance of Physiotherapy Regulators as not substantially different

•

successfully complete the written component of the Physiotherapy Competency Exam

•

have attempted and not successfully completed the clinical component of the PCE on only one occasion or been scheduled to do so and did not complete the exam as scheduled

To apply to the College for a Provisional Practice with Restrictions Certificate, the Physiotherapy Resident must: •

submit a Provisional Practice with Restrictions Plan and Agreement that demonstrates that they will have the full and direct supervision of a physiotherapist(s) with a current Independent Practice Certificate while they are practicing and

•

provide evidence that they are registered for the next available sitting of the clinical component of the PCE.

Provisional Practice with Restrictions Application Information

Section 1—Page 3

Provisional Practice with Restrictions Plan and Agreement The Provisional Practice with Restrictions Plan and Agreement is a written contract between the Physiotherapy Resident, the Supervisor and the College that outlines the responsibilities of both the Physiotherapy Resident and the Supervisor. The Provisional Practice with Restrictions Plan and Agreement is prepared by the Resident and Supervisor(s) and must be sent with the Provisional Practice with Restrictions application . The Provisional Practice with Restrictions Plan and Agreement states that the Supervisor(s) will be on site at all times and provide full and direct supervision when the Physiotherapy Resident is providing patient care. Telephone contact does not constitute on-site supervision. Physiotherapy Residents may have up to three supervisors as long as they meet the requirements and their name is shown on a Provisional Practice with Restrictions Agreement.The primary supervisor will act as the main contact for the College and oversee communication with all parties, ensure that the supervision plan is followed, and will be responsible for the majority of the supervision of the resident. The Agreement must be reviewed and approved by the College before the Physiotherapy Resident is allowed to practice with Provisional Practice with Restrictions. The Agreement must include: •

a plan of onsite supervision including identification of all Supervisors;

•

a plan to coordinate the supervision of the Physiotherapy Resident;

•

a primary contact person—the Primary Supervisor; and

•

mechanisms for providing supervision such as direct observation, review of documentation, case reviews and meetings between the Physiotherapy Resident and Supervisor.

Supervisor’s Requirements and Responsibilities The goal of Provisional Practice with Restrictions is to ensure that the Physiotherapy Resident practices and delivers physiotherapy services that are safe, ethical and effective and that there is no undue risk of harm to the public. The Supervisor must: •

hold an Independent Practice Certificate and have a minimum of two years physiotherapy practice experience.

•

consider the time and the resources needed for full and direct supervision to determine their ability to achieve the necessary level of supervision.

•

be on-site at all times during which the Physiotherapy Resident is involved in direct patient care activities.

•

be able to provide observation and contact to ensure clinical competency. However, the Supervisor is not required to be in the same room with the Physiotherapy Resident at all times. Supervision via telephone is not considered to be on-site supervision. (The supervisor does not have to be onsite if the Resident is involved in non-direct patient activities such as documentation or research activities).

Provisional Practice with Restrictions Application Information

Section 1—Page 4

•

include activities such as formal and informal observation, review of documentation, case reviews, meetings with the Physiotherapy Resident and input from team members. Supervision may also include chart audit, demonstration of skills, formal performance review or project management.

•

complete a formal evaluation of the Physiotherapy Resident using the Clinical Performance Instrument (CPI) on dates provided by the College.

•

immediately, within one business day, inform the Entry to Practice team of any professional practices, incidents, conduct, incompetence or incapacity on the part of the applicant that may affect patient care or public safety. Examples where contact with the College may be necessary include (but are not limited to) committing a breach of confidentiality or privacy, crossing boundaries, inappropriate billing, incapacity, a breach of the code of ethics, not seeking informed consent or any behaviour or action that endangers the public safety.

•

Supervise the Physiotherapy Resident’s clinical practice in order to evaluate and ensure clinical competencies of the following: •

assessment;

•

client goal setting;

•

treatments;

•

maintenance of client records and reports;

•

the use of outcome measures;

•

interaction and communication with clients and family;

•

interaction and communication with other agencies and service providers;

•

adherence to the Standards for Professional Practice and legislation.

Methods of Supervision may include: •

chart audit;

•

videotape reviews;

•

performance reviews; and

•

peer reviews.

Provisional Practice with Restrictions Application Information

Section 1—Page 5

Resident’s Requirements and Responsibilities Before the restrictions period begins, the Physiotherapy Resident must: •

tell their employer of the expiry of his or her Provisional Practice certificate (if applicable) and assist with interim arrangements to minimize disruption of care to patients;

•

initiate discussion about the ability and willingness of the employer to provide full onsite supervision and support to the Physiotherapy Resident in their application for Provisional Practice with Restrictions;

•

develop and complete a plan of supervision with the supervisor and employer;

•

complete and submit all documentation related to the application for Provisional Practice with Restrictions.

During the restrictions period, the Physiotherapy Resident must: •

ensure that all patients continue to be aware of their Physiotherapy Resident status and obtain consent to treatment; and

•

tell the College as to any changes to their practice or supervision and obtain College approval for any proposed change to the Provisional Practice with Restrictions plan before the change occurs.

Joint Responsibilities The Resident and the Supervisor will develop, maintain and comply with the Provisional Practice with Restrictions Agreement and must ensure ongoing communication with the College. The Provisional Practice with Restrictions Agreement must be completed and signed by the Supervisor(s) and the Resident and submitted to the College before a Certificate for Provisional Practice with Restrictions will be issued. Physiotherapy Residents must also include evidence that they have registered for the next sitting of the clinical component of the Physiotherapy Competency Exam (PCE) with their application.

Provisional Practice with Restrictions Application Information

Section 1—Page 6

Registration for Provisional Practice with Restrictions Application Guide The College of Physiotherapists of Ontario is pleased to provide this guide to help you complete your application for an Provisional Practice with Restrictions certificate. Please review this guide prior to completing your application form.

Practice Name You are required to ensure that the name you use in practice is the same as the way that your name appears on the Public Register. Your practice name will appear on the College’s Public Register. The Public Register is a list of all currently registered and past registered physiotherapists in Ontario. It provides the public with the physiotherapist’s information and history with the College and acts as proof of registration for physiotherapists.

Previous Last Name Enter your previous last name(s) if you have changed your name since completing your physiotherapy education. If the name which you wish to register under is different than the name on your educational qualifications or your immigration or citizenship documents, you must provide a photocopy of your marriage certificate, divorce decree, or legal name change document.

Home Mailing Address Please provide your home mailing address. The College will occasionally mail you important information. The College does not provide your home address to any source outside the College, unless you have indicated that this is also your business address. Please ensure that you provide complete information.

Email Address The College requires that all members have an active email address used for communication with the College. Confidential information may be sent by email, so please ensure that the email address that you provide is secure.

Language(s) Indicate the languages in which you are capable of providing physiotherapy services. This information will be provided to members of the public who are seeking physiotherapy services in a specific language. You must also indicate the language in which you prefer to receive official documents. The College will attempt to accommodate this preference whenever possible.

Provisional Practice with Restrictions Application Guide

Section Section 1—Page 2—Page 77

Education Provide information about your initial physiotherapy education in this section. Include the name of the educational program, the year of graduation, the academic institution and the location of the academic institution (province/state if Canada or US and country). If Provisional Practice with Restrictions is the inital certificate of registration with the College, you must provide evidence of a degree in physiotherapy. Please submit any one of the following: •

A notarized photocopy of your degree; or

•

Arrange for notification to be sent directly to the College from the educational institution which issued the degree (if the College is receiving a university list with your name on it, we would also appreciate a photocopy of your degree to keep on file when it becomes available); or

•

Bring your original degree to the College and entry to practice staff will photocopy it onsite

When you graduate from an Ontario university, a letter from the university outlining your completion of the program will be sent to the College and will meet this requirement. You will still be required to provide a photocopy of your degree when you apply for an Independent Practice certificate. When asked to provide additional physiotherapy education and other education, please provide information about any other formal education that you completed. The College does not require information about continuing education programs or certifications. Only programs where degrees are granted should be included in this section.

Eligibility to Work in Canada To register with the College you must be legally eligible to work in Canada. This means you must provide one of the following with your application: 1. Proof of Canadian Citizenship. • A photocopy of your Canadian birth certificate, a photocopy of your Canadian passport photo page or a photocopy of both sides of your citizenship card must be provided as proof of Canadian citizenship. 2. Permanent Resident/Landed Immigrant of Canada • A photocopy of your permanent resident card or document must be included with your application. 3. A valid work permit •

A photocopy of your valid work permit indicating that you are eligible to work in Canada must be included. This work permit must not prohibit you from working as a physiotherapist.

Information about the Physiotherapy Competency Exam For College registration purposes once the deadline for the examination application has passed, as published by the Canadian Alliance of Physiotherapy Regulators, it is considered no longer available.

Provisional Practice with Restrictions Application Guide

Section Section 1—Page 2—Page 88

Registration, Licensure & Past Practice You must tell the College of all of the places you have practiced physiotherapy. If the country is not regulated, you must still provide us with the dates you practiced there. If the country is regulated you must provide us with proof of registration/ licensure AND good standing. You can submit any one of the following: •

a letter of professional standing,

•

verification of registration form, or

•

by providing the College with a website address where the information can be verified online

Letters of professional standing must be dated within six (6) months of the application date.

Your Practice History in Physiotherapy The College is required to provide de-identified information to the Ministry of Health and Long-Term Care which is used for health human resources planning and to better understand labour mobility patterns.

Professional Conduct If you answer YES to any questions, please provide further information. Your application will then be referred to the Registration Committee for a decision related to your registration application. The College will contact you to inform you of the process and what to do next.

Professional Liability Insurance According to the College’s by-law on professional liability insurance, if you are going to provide patient care, you are required to hold professional liability insurance. You must declare that you have or will have professional liability insurance before you begin to provide patient care in Ontario. Professional liability insurance should: 1. Be obtained individually or through your employer 2. Have a minimum coverage of $5 million for any one patient and for the policy year 3. Have no deductible

Patient Care The College defines Patient Care as assessing people for physiotherapy needs, consulting with people, and providing treatment in settings such as schools, companies, fitness centres, or institutions. It includes weekend and relief work, and taking over when someone is on vacation. If you assign others to work with patients, the College also considers this to be patient care. One interaction with one patient per year is defined as patient care.

Provisional Practice with Restrictions Application Guide

Section Section 1—Page 2—Page 99

Information about Your Work Site The College collects details about each work site that you are working at. This means that if you work for one employer, but at two different work sites, you need to provide information about each location. This information is made public on the College Public Register and must be accurate and up-to-date. You must notify the College of any change to your employment within 30 days of the change happening.

Declaration You must sign, check off and date the declaration section of the form in order for your application for registration to be complete. The declaration confirms that all of the information you have provided in the application is true and correct. If you provide incorrect or false information, you could be denied registration or any registration issued to you could be revoked (taken away).

Provisional Practice with Restrictions Application Guide

Section Section 1—Page 2—Page 10 10

General Application Information Incomplete Applications Applicants who submit incomplete applications will be notified by email. A list of missing documentation will be provided. You are welcome to submit your documents as they become available; however applications will not be processed until they are complete. The processing time for applications will not begin until the completed application, all additional documentation and fees have been received. Processing Time The College will attempt to process your application for registration within ten business days of receiving the completed application form and all required documentation. If you have pre-registered, your application will be processed within five business days. If there is doubt whether your application meets all of the registration requirements, it will be referred to the Registration Committee for review. You will be contacted by College staff with more information if your application is referred to the Registration Committee. Longer timelines will apply under these circumstances. Confirmation of Registration An email will be sent to you to confirm your registration once your application has been processed. Privacy The personal information collected on this form is used by the College of Physiotherapists of Ontario for its regulatory purposes (e.g., the registration and identification of College members, the administration of statutes governing physiotherapists in Ontario and the administration of the College) and to develop and provide statistical information for human resource planning, demographic and research studies and eHealth Ontario. It is collected under the authority of the Regulated Health Professions Act, the Health Professions Procedural Code, the Physiotherapy Act and the regulations and by-laws made under the authority of these statutes. The College does not sell this information, nor does it provide the information to commercial entities in a format that facilitates mass marketing. For more information about the Privacy Code, please contact the College. Document Retention The College has moved to electronic maintenance and storage of member files. Electronic copies of member applications and documents will be stored indefinitely. When you submit your application to the College, if there are any hard copy documents that you would like us to return to you, please let us know.

Provisional Practice with Restrictions Application Guide

Section Section 1—Page 2—Page 11 11

Document Checklist Please ensure that your application includes all of the following: Provisional Practice with Restrictions Application Form Signed Plan and Agreement Written evidence from the Alliance confirming that you are registered in the next available clinical component of the PCE The appropriate fees If you have never been registered before, you must also provide the following: A photocopy of Canadian citizenship, permanent resident status or an authorization under the Canadian Immigration Act to work in Ontario. You may submit a photocopy of any one of the following:

• Proof of Canadian Citizenship • Canadian birth certificate, • Canadian passport photo page or • both sides of your citizenship card

• Permanent Resident/Landed Immigrant of Canada • A Valid Work Permit Evidence of a degree in physiotherapy. Evidence includes any one of the following:

• A notarized photocopy of your degree; or • Arrange for notification to be sent directly to the College from the educational institution which issued the degree (if the College is receiving a university list with your name on it, we would also appreciate a photocopy of your degree to keep on file when it becomes available); or

• Bring your original degree to the College and entry to practice staff will photocopy it onsite A small photograph of you (either digital or printed) If this applies to you: Proof of registration/licensure and professional standing in all other jurisdictions where you have been registered/licenced as a physiotherapist A photocopy of your name change document

Provisional Practice with Restrictions Application Guide

Section Section 1—Page 2—Page 12 12

Provisional Practice with Restrictions APPLICATION FORM This form is for all members who were unsuccessful at their first attempt of the Clinical Component or did not complete the Clinical Component as scheduled. This category requires full and direct onsite supervision from a supervisor and will involve the submission of the Clinical Performance Instrument.

1. Personal Information Last name: ____________________________ Previous Last Name: ___________________________________ (if you had a different last name in the past, please provide it)

First name: ________________________________________ Middle name: ______________________________ Name you use to practice physiotherapy: _________________________________________________________ Home address: _____________________________________________________________________________ City/Town:

_____________________________________________________________________________

Province: ______________________Country: ___________________________Postal code: _______________ Home telephone: __________________________________ Cell phone: ________________________________ Email: _____________________________________________________________________________________ Birth Date: ___________________________________

Gender:  Female

 Male

(mm/dd/yy)

2. Language I can provide physiotherapy services in: (choose all that apply)

 English

 French

 Other: _________________________________________________

I prefer to receive College documents in*: (choose one)

 English

 French

*Communication is primarily in English and this selection will be accommodated for official documents only whenever possible.

FOR OFFICE USE ONLY Date Received:

_______________________ Date Complete:

______________________

Registration Date:

_______________________ Registration Number:

______________________

Processed By:

_______________________ Pre-Registered:

 Yes  No

Professional Conduct: _______________________

Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 13 13

3. Education 3.1 Initial Physiotherapy Education What is the initial physiotherapy education you completed? Level of Education:

 Diploma

 Baccalaureate

 Masters

 Professional Doctorate

 Other: ___________________________________________________ Year of Graduation: _______________ Name of Educational Institution: ________________________________________________________________ Province/State: ___________________________________ Country: ____________________________________

3.2 Do you have more Physiotherapy Education? Starting with the most recent, please tell us about formal physiotherapy programs where you obtained a degree or diploma after your initial physiotherapy education? Level of Education:  Baccalaureate  Master  Professional Doctorate  Doctorate

 Baccalaureate  Master  Professional Doctorate  Doctorate

 Baccalaureate  Master  Professional Doctorate  Doctorate

Name of Educational Institution:

Name of Educational Institution:

Name of Educational Institution:

Province/State:

Province/State:

Country:

Country:

Year of Graduation:

Year of Graduation:

Province/State:

Level of Education:

____

Country:

_

_____

Year of Graduation:

___

Level of Education:

3.3 Education Other than Physiotherapy Please tell us about other formal education where you obtained a degree or diploma. The College does not require information about all continuing education courses. GRS MLS HAM PAD PHE KIN GER PSY OHP BBS

General Rehabilitation Science Medical Laboratory Science Health Administration/ Management Public Administration Public Health Kinesiology/Exercise Science Gerontology Psychology Other Health Profession/Related Clinical Sciences Biological and Biomedical Sciences

PHY SAH EDU LAW BMM MCI ENG OSC OFS

Physical Sciences Social Sciences, Arts and Humanities Education Law Business, Management, Marketing and Related Mathematics, Computer Information Sciences Engineering Other Sciences Other Field of Study

*Field of Study— Please use the applicable 3 letter code in the above section *Field of Study: Level of Additional Education:  Diploma  Baccalaureate  Master  Professional Doctorate  Doctorate

*Field of Study: Level of Additional Education:  Diploma  Baccalaureate  Master  Professional Doctorate  Doctorate

*Field of Study: Level of Additional Education:  Diploma  Baccalaureate  Master  Professional Doctorate  Doctorate

Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 14 14

Name of Educational Institution:

Name of Educational Institution:

Name of Educational Institution:

Province/State:

Province/State:

Province/State:

____

Country:

____

Country:

Year of Graduation:

___

____

Country:

Year of Graduation:

___

Year of Graduation:

___

3.4 Educational Bridging Program Did you complete an Ontario Bridging Program for Internationally Educated Physiotherapists?  Yes

If yes, what year: Where:  Ryerson University  University of Toronto

 No

4. Information about the Physiotherapy Competency Exam I have successfully completed the written component of the Physiotherapy Competency Examination (PCE). Date of Completion: __________________________________________________________ I am registered in the next available clinical component of the PCE. Date of Clinical: __________________________________________________________ I have attempted the clinical component of the PCE in the past. Please provide the date(s): __________________________________________________

5. Registration, Licensure and Past Practice 5.1 Your practice of PHYSIOTHERAPY IN ONTARIO: Have you ever been registered to practice physiotherapy in Ontario?

 Yes:

I was registered from: _____________ to ____________ Registration number: ________________

 No 5.2 Your practice of PHYSIOTHERAPY OUTSIDE OF ONTARIO: Have you ever practiced physiotherapy outside of Ontario?

 Yes: Please provide details about all locations, even if no professional licencing existed below.  No Province/State

Country

Licence/Reg. No.

Dates

____________________

________________________ _______________________ ____________________

____________________

________________________ _______________________ ____________________

____________________

________________________ _______________________ ____________________

Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 15 15

5.3 Your practice in OTHER PROFESSIONS: Have you ever been registered or licenced in any other regulated profession?

 Yes: Please provide details about all locations and regulated professions.  No

Profession

Province/State, Country

Licence/Reg. No.

Dates

____________________

________________________ _______________________ ____________________

____________________

________________________ _______________________ ____________________

____________________

________________________ _______________________ ____________________

6. Your Practice History in Physiotherapy By law, The College must provide general information about the physiotherapy profession to the Ministry of Health and Long Term Care in Ontario. We do not give the Ministry your name or link your name to the answers you provide below. You must answer these questions. 6.1 . Is Canada or the United States the first country where you have practiced physiotherapy?  Yes

 No

a.

If yes:

Which province or state did you practice in?_________________________ What Year did you first register there?___________

b.

If no:

Where was the first Country you practiced? ____________________________________ What was the name of the province or state? ___________________________________ What Year did you first start? __________________________

6.2 Is Canada or the United States the most recent previous Country of practice?  Yes  No a.

If yes:

Which province or state did you practice in?_________________________ When did you last practice?_________________________

b.

If no:

Where is the most recent previous country you practiced Physiotherapy?____________________ What was the name of the province or state? ___________________________________ Are you still practicing Physiotherapy or registered in this country?

 Yes If yes, what is the expiry date? ___________________________________  



 No

Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 16 16

7. Professional Conduct If you answer YES to any of the following questions please provide more information. 7.1 Have you ever had a finding of professional misconduct, incompetence or incapacity against you?  No

 Yes

If Yes, Where? _____________________ When? ____________________ More information:

7.2 Have you ever had an application for a physiotherapy practice certificate or licence refused?  No

 Yes

If Yes, Where? _____________________ When? ____________________ More information:

7.3 Have you ever had a physiotherapy practice certificate or licence suspended or taken away (revoked)?  No

 Yes

If Yes, Where? _____________________ When? ____________________ More information:

7.4 Have you ever been found guilty of an offense, professional negligence or malpractice?  No

 Yes

If Yes, Where? _____________________ When? ____________________ More information:

8. Professional Liability Insurance Physiotherapists who provide patient care in Ontario must have professional liability insurance that meets the by-law requirements. More information can be found in the Application Guide. Please check the box that applies to you:  I already have professional liability insurance OR  I will have professional liability insurance before I begin patient care.

Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 17 17

9. Information about your Work Site Please complete the employment information for each site where you will be working. Work site #1 is the site that you are at most of the time. Each employment site must have a complete business address. All employment information is public and will be available on the Public Register. Do you work at more than three employment sites?

Yes*

No

*If yes, please attach additional pages and provide all required information about each site.

Work Site #1 Name of Work Site

Start Date

Street Address City

Province/State

Country

Postal Code/Zip Code

Business Phone No.

Ext.

Fax No.

Work Site #2 Name of Work Site

Start Date

Street Address City

Province/State

Country

Postal Code/Zip Code

Business Phone No.

Ext.

Fax No.

Work Site #3 Name of Work Site

Start Date

Street Address City

Province/State

Country

Postal Code/Zip Code

Business Phone No.

Your Position Type

Ext.

Fax No.

Please choose only one per site. First Site

Second Site

Third Site

Permanent Employee







Temporary (Contract) Employee







Casual Employee







Employee (Other)







Self-Employed







Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 18 18

Which Do You Work?

Please choose only one per site. First Site

Second Site

Third Site

Full-time







Part-time







Casual







Your Position or Job Title

Please choose only one per site. First Site

Second Site

Third Site

Manager







Owner/Operator







Service Provider







Consultant







Administrator







Instructor







Researcher







Quality Manager







Sales Person







Other







Describe Your Worksite

Please choose only one per site. First Site

Second Site

Third Site

Hospital







Solo Professional Practice







Group Professional Practice







Rehabilitation Facility







Residential/Long-Term Care Facility







Visiting Agency/Business (Client’s Environment)







Community Care Access Centre (CCAC)







Post-Secondary Educational Institution







Assisted Living Residence/Supportive Housing







Community Health Centre (CHC)







Family Health Team







School or School Board







Children’s Treatment Centre (CTC)







Other Pediatric Facility







Cancer Centre







Mental Health and Addiction Facility







Fitness Centre







Association/Government/Regulatory or Similar







Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 19 19

Board of Health or Public Health







Telephone Health Advisory Services







Health-Related Business/Industry







Other Industry—Manufacturing and Commercial







Spa







Correctional Facility







Nurse Practitioner Led Clinic







Group Health Centre (Sault Ste. Marie only)







Other







What is the focus of your Practice?

Please choose only one per site. First Site

Second Site

Third Site

Clinical Focus on Musculoskeletal System







Clinical Focus on Neurological System







Clinical Focus on Cardiovascular & Respiratory System







Clinical Focus on Skin & Related Structures







Clinical Focus on More than One System







Non-Clinical Focus







What is the main area of Practice you are involved in? Patient Care:

Please choose only one per site. First Site

Second Site

Third Site

General Practice







Sports Medicine







Burns and Wound Management







Plastics







Amputations







Orthopedics







Rheumatology







Vestibular Rehabilitation







Women’s Health/Uro-genital







Cancer Care







Geriatric Care







Chronic Disease Prevention and Management







Cardiology/Cardiovascular







Continuing Care/Long-Term Care







Public Health







Critical Care/ICU







Mental Health and Addiction







Neurology/Neuroscience







Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 20 20

Respirology/Cardio-respiratory







Health Promotion and Wellness







Palliative Care







Return to Work Rehabilitation







Ergonomics







Other Area of Direct Service







Infectious Disease Prevention and Control







Emergency







Client Service Management/Case Management







Consultation







Administration







Teaching (Physiotherapy entry-level)







Physiotherapy-Related Continuing Education Teaching







Other Teaching







Quality Management







Research







Sales







Other: Area of Practice

What job sector do you work in?

Please choose only one per site. First Site

Second Site

Third Site

Public Sector







Private Sector







Combination of Public and Private







Not Sure







Main Category of Patients

Please choose only one per site. First Site

Second Site

Third Site

All Ages







Pediatric







Adult







Geriatric







Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 21 21

Do you provide patient care?

Please choose only one per site. First Site

Second Site

Third Site

Yes







No







The College defines Patient Care as any component of assessment, analysis of findings or provision of treatments to patients for whom you are directly responsible. This includes the assignment of any portion of care to support personnel. Note: This includes roles involving assessment, consultation or provision of treatment in schools, industry, fitness centres, occasional weekend or relief work or short-term vacation coverage. Even an interaction with one patient per year is defined as patient care.

Are you accepting new patients?

Please choose only one per site. First Site

Second Site

Third Site

Yes







No







This information will be used to assist the public in locating a physiotherapist.

In your main work site, do you prefer to work:

Full-time

Casual

Part-time

Not applicable

Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 22 22

10. Fees Please check the applicable amount in each section.

Application Fees Application Fee (applies to new applicants) No application fee as I have held a certificate of registration with the College that has terminated within the last year.

Registration Fees Certificate of Registration Authorizing Provisional Practice with Restrictions

Fee

Check Selection

$100.00



–



Fee

Check Selection

$75.00



Credit card payment (Please note: the College of Physiotherapists of Ontario does not accept Visa Debit)

 Visa

 MasterCard

Card Number:

Authorized payment amount: $ Expiry Date:

Cardholder’s Name: Cardholder’s Signature:

_____________________

11. Additional Information Please provide any additional information that you want the College to be aware of:

Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 23 23

12. Declaration  I hereby certify that the statements made by me in this application are complete and correct to the best of my knowledge and belief. I understand that a false or misleading statement may disqualify me from registration or may be cause for any registration which may be granted to me to be taken away (revoked).  I understand that I must notify the College through the online registration system or in writing by fax, email or mail of any change to my address, phone number or employment information within thirty days of the change occurring.  I understand that I must notify the College immediately of any change to my Plan and Agreement.

Applicant Signature

Date (mm/dd/yyyy)

Please note: The College maintains electronic copies of all application forms and submitted documents indefinitely.

Please return this form to the College, by using any of the three methods below. Hours of Operation: Monday–Friday (excluding statutory holidays) 8:30am–4:30pm By mail or in person: College of Physiotherapists of Ontario ATTN: Entry to Practice Associate 375 University Avenue, Suite 901 Toronto, ON M5G 2J5

By fax: 416-591-3834

By scanning and emailing: [email protected]

Tel: 416-591-3828 ext. 222 Toll-free: 1-800-583-5885 ext. 222

Provisional Practice with Restrictions Application Form

Section Section 1—Page 3—Page 24 24

ProvisionalProvisional Practice with Restrictions isional Practice PLAN AND AGREEMENT This document must be submitted to the College before a Certificate of Provisional Practice with Restrictions can be granted. Name of Applicant: __________________________________________________________________________

PRIMARY SUPERVISING PHYSIOTHERAPIST The Primary Supervisor is the physiotherapist who will provide the majority of supervision and complete all reports for the College. When there is more than one supervisor involved, the Primary Supervisor will ensure coordination and ongoing communication between all parties. The Primary Supervisor will be the main contact with the Resident, the College and any other supervisors.

Please provide the facility name, business address and telephone number of the site where the supervision will occur. Facility Name Facility Address

Suite No.

City Province/State

Postal Code

Facility Phone No.

Email Address

1.0 SUPERVISORS* Supervisor First Name

Supervisor Last Name

Registration Number

Estimated Hours of Supervision

Primary Secondary Tertiary** * Supervisors must have a minimum of two years of physiotherapy practice experience. ** Typically there will be one Primary Supervisor who may be assisted by a second supervising therapist. A third supervisor may be identified to support the supervision of a resident in the event of illness or vacation.

Provisional Practice with Restrictions Application—Plan and Agreement

Section 4—Page 25

Practice ProvisionalProvisional Practice with Restrictions PLAN AND AGREEMENT 2.0 OVERALL COORDINATION If more than one Supervisor will be involved, describe how the Primary Supervisor will organize the overall coordination of the supervision. Describe how the Primary Supervisor will ensure effective feedback and communication is maintained between all parties.

3.0 SUPERVISION PLAN Describe how you will supervise this Resident. Supervision must include the following activities; formal and informal observation, review of documentation, case reviews, meetings with the Resident and input from team members. Supervision may also include chart audit, demonstration of skills, formal performance review or project management. Supervision requires that you (or another Supervisor) be onsite at all times when the Resident is involved in direct patient care.

4.0 RESIDENT’S CASELOAD Please describe the Resident’s caseload (e.g. orthopaedic, neurological) and the typical number of patients per day.

Provisional Practice with Restrictions Application—Plan and Agreement

Section Section 1—Page 4—Page 26 26

APPLICANT I, _____________________________________________________________, agree to comply with the terms, conditions and limitations associated with a Certificate Authorizing Provisional Practice with Restrictions. I agree that I shall only practice as a member of the College of Physiotherapists holding a Provisional Practice with Restrictions Certificate while under the supervision of the person named in this agreement and at the specified facility. I agree to assume responsibility for informing the College of any proposed changes to the Provisional Practice with Restrictions Plan and understand that in the event that either the supervisor or employment facility changes, I will be required to submit a new application, which must be approved by the College before I can resume Provisional Practice with Restrictions. I understand that I will use the title Physiotherapy Resident and that this Certificate for Provisional Practice with Restrictions will not be re-issued.

Signature of Applicant

Date (mm/dd/yyyy)

SUPERVISOR I, _____________________________________________________________, agree to provide supervision for the above named applicant in accordance with the Requirements and Responsibilities specified by the College regarding Provisional Practice with Restrictions. I agree to comply with this Provisional Practice with Restrictions Plan and understand that I am agreeing to directly supervise this Physiotherapy Resident. As part of my supervisory responsibilities, I agree to formally evaluate the Resident and will report (within one business day) to the College of Physiotherapists of Ontario any professional practices, incidents, conduct, incompetence or incapacity on the part of the applicant that in any way may adversely affect patient care or public safety. I will notify the College immediately if I am unable to fulfill my responsibility as a Supervisor.

Signature of Primary Supervisor

Date (mm/dd/yyyy)

If applicable:

Signature of Supervisor (2)

Date (mm/dd/yyyy)

Signature of Supervisor (3)

Date (mm/dd/yyyy)

Please return this form to the College, by using any of the three methods below. Hours of Operation: Monday–Friday (excluding statutory holidays) 8:30am–4:30pm By mail or in person: College of Physiotherapists of Ontario ATTN: Entry to Practice Associate 375 University Avenue, Suite 901 Toronto, ON M5G 2J5 Tel: 416-591-3828 ext. 222 Toll-free: 1-800-583-5885 ext. 222

By fax: 416-591-3834

By scanning and emailing: [email protected]

Provisional Practice with Restrictions Application—Plan and Agreement

Section Section 1—Page 4—Page 27 27