Continuing Competence Forms

Clinical Instructor Documentation

Rule .0109 (d) (3) describes how points may be earned and documented for service as a Clinical Instructor:

(d) Clinical Education Activities are eligible for points as follows: (3) For serving as a Clinical Instructor for a physical therapist or physical therapist assistant student, resident or fellow for a period of at least 80 hours, 40 hours of direct supervision earns one point, and a maximum credit of eight points is allowed during any reporting period. The licensee shall submit verification of the clinical affiliation agreement with the accredited educational program for the student supervised and a log showing the number of hours spent supervising the student.

To earn continuing competence points under this rule, the information that follows provides suggestions for appropriately documenting this activity. 

1. A. Clinical Instructor for Physical Therapy Student or Physical Therapist Assistant Student: (both (a) and (b) required)
1. Verification of the Clinical Affiliation Agreement with the accredited educational program
1.   Verification of the Clinical affiliation agreement  Form or,
2.   Certificate of Recognition for Clinical Instructor Participation  or
3. A letter verifying the student clinical education experience that includes this or similar wording:
1. With appropriate signatures from the academic educational institution (Academic Coordinator of Clinical Education, ACCE) and the clinical facility (Center Coordinator of Clinical Education, CCCE)
2. Dates of rotation or description of length of the rotation.  Example: “… 20 week internship from October 27, 2008 to March 20, 2009. “  OR “…student completed clinical instruction from January 5 through February 13, 2009 for a total of 6 weeks (225 hours) at your facility.”
2. Verification of Clinical Instruction Hours
1.  Suggested form for recording Clinical Instruction hours or
2. Create a verification of hours form “on your own” which should be signed by the Center Coordinator of Clinical Education (CCCE) and the Clinical Instructor (CI). 

1. B. Clinical Instructor for Resident and Fellowship Participants: (both (a) and (b) required)
1. Verification of the Residency or Fellowship agreement:
1. Letter of Acceptance to the Resident/Fellow from the APTA Credentialed Residency or Fellowship including dates of the residency/fellowship and program requirements OR
2. Contract with the Residency or Fellowship Program OR
3. Letter of Appointment to the Residency or Fellowship program
2. Verification of Clinical Instruction Hours:
1.  Suggested form for recording Clinical Instruction hours or
2. Create a verification of hours form “on your own” which should be signed by the Organizational Administrator or Program Director and Clinical Instructor (CI). 
      
   

Physical Therapy Licensee Clinical Practice Certification Form

 Physical Therapy Licensee Clinical Practice Certification Form Updated 5-31-13
Physical Therapy licensees may earn continuing competence points by performing and documenting clinical practice.  This form may be used to document clinical practice hours for continuing competence points; however,  it is not required.    An employer or licensee may develop one of their own. 

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Continuing Competence Verification of Attendance

 NCBPTE Continuing Competence Verification of Attendance Form Updated 01-14-19

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Continuing Competence Exemption Request Form

 Continuing Competence Exemption Request Form Added 10-17-2022