Application Package. Provisional Practice. September College of Physiotherapists of Ontario

Transcription

1 Application Package Provisional Practice September College of Physiotherapists of Ontario

2 Provisional Practice Application Package Provisional Practice is a registration category that covers the period after the completion of physiotherapy education or credentialing and passing the written component of the Physiotherapy Competency Examination (PCE) and prior to passing the clinical component of the PCE. This package includes an information sheet, an application guide and form and a Monitoring Agreement. Section 1 Provisional Practice Information page 3 Section 2 Application for Registration Guide page 6 Section 3 Application Form (to be completed by Applicant) page 12 Section 4 Monitoring Agreement (to be completed by Applicant and Monitor) page 25 For questions about registration and applying to the College, please contact: Entry to Practice team ext. 222 or ext. 222 registration@collegept.org College of Physiotherapists of Ontario 375 University Avenue, Suite 901, Toronto, ON M5G 2J5 Tel: or Fax: Provisional Practice Application Information Page 2

3 Provisional Practice Information New graduates and recently credentialed international applicants have the option to register with a Provisional Practice certificate as a Physiotherapy Resident. Members in this category have successfully completed the written component of the Physiotherapy Competency Exam (PCE) and have registered for the next available clinical component of the PCE. An individual holding a Provisional Practice certificate must use the title Physiotherapy Resident. To apply for Provisional Practice you must have a job secured and a monitor. It is not mandatory for the monitor to be onsite when the Physiotherapy Resident is working. However, the monitor must assure that the Resident carries out her/his clinical responsibilities safely and competently. The Resident is issued a registration number entitling him or her to perform controlled acts (if rostered), bill for physiotherapy services and complete client records. Physiotherapy Residents are accountable to the College for their actions. The Monitoring Agreement Both the Physiotherapy Resident and the Monitor are responsible for ensuring that monitoring requirements and the terms, conditions and limitations of registration under Provisional Practice are met. The key responsibilities include: 1) ongoing monitoring of practice; 2) completion of the Monitoring Agreement; 3) completion of the Monitoring Tool at specified times provided by the College; and 4) communicating as appropriate with the College. Monitoring may include activities such as direct observation, meetings and case reviews, chart audits and discussions with other team members. The College recognizes that monitoring activities will vary depending on the type of the employment setting, the area of practice, the resident s job description and available resources. These factors influence the way the monitor oversees the resident at work. The ultimate goal of monitoring is to ensure the delivery of safe physiotherapy services and the protection of the public. The Monitoring Agreement acts as the formal agreement between the Monitor and the College. The Monitoring Agreement must be completed, signed and dated, and sent to the College with the application for review before the applicant will be granted a certificate of registration. Page 3 Page 3 Provisional Practice Application Information Section 1 Page 3

4 The Monitor must: be a holder of an Independent Practice Certificate. have two years practice experience as a physiotherapist. not have any restrictions on their certificate of registration that does not allow them to monitor. sign and submit the Monitoring Agreement. monitor the Physiotherapy Resident s practice to ensure that the delivery of physiotherapy services is safe and that there is no undue risk of harm to the public. determine methods of monitoring with the Resident. These may include: Direct observation, Chart audit, Meetings and case reviews, and Feedback from other health team members. Complete the Monitoring Tool by the dates set by the College immediately (within one business day) contact the Entry to Practice team, if the Resident performs any act of professional misconduct, or of incompetence, or if the Physiotherapy Resident appears incapacitated. be available for communication and consultation with the Resident. provide follow up information to the College of any concerns about the Resident identified in the monitoring process tell the College if unable to carry out his or her responsibilities for a period of more than two weeks. If the Resident is without an approved Monitor the Resident cannot practice. Provisional Practice Application Information Section 1 Page 4

5 Changing Monitors while Holding Provisional Practice Registration During provisional practice if you need to change your monitor you must notify the College immediately and resubmit a new monitoring agreement before you change monitors. Once the new monitor is approved you are allowed to continue to practice as a physiotherapy resident. The Physiotherapy Resident must: be applying for a Provisional Practice certificate of registration for the first time unless he or she was unable to complete the Physiotherapy Competency Exam (PCE) successfully due to an illness or some other reason beyond his or her control. In these cases, the Registration Committee will decide, on a case by case basis and after a thorough review, whether to grant a certificate. have a job secured find a monitor and ensure he/she is informed about his or her role and responsibilities. submit all documents and fees related to the application to the College for approval and obtain a registration number before starting to work. alert the College, find a new monitor and submit a new Monitoring Agreement to the College if the monitor is unable to carry out their responsibilities for more than a two-week period. If the resident does not have an approved monitor, he or she cannot practice. notify the College and obtain approval for any proposed change to the Monitoring Agreement prior to the change occurring. tell the College if there is any change to his/her employment within 30 days of the change occurring. remain registered for the next sitting of the clinical component of the Physiotherapy Competency Exam (PCE). The resident must contact the Entry to Practice team if there are any changes to the date of his or her exam to inquire about the possibility of getting a 2nd Provisional Practice certificate. Provisional Practice Application Information Section 1 Page 5

6 Registration for Provisional Practice Application Guide The College of Physiotherapists of Ontario is pleased to provide this guide to help you complete your application for an Provisional Practice 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. Address The College requires that all members have an active address used for communication with the College. Confidential information may be sent by , so please ensure that the 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 Application Guide Section 1 Page 2 Page 6

7 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). Evidence of a degree in physiotherapy is required for registration. 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. Provisional Practice Application Guide Section 1 Page 2 Page 7

8 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. 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. Registration, Licensure & Past Practice You must tell the College about 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. Provisional Practice Application Guide Section 1 Page 2 Page 8

9 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 Application Guide Section 1 Page 2 Page 9

10 General Application Information Incomplete Applications Applicants who submit incomplete applications will be notified by . 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 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 Application Guide Section 1 Page 2 Page 10

11 Document Checklist Please ensure that your application includes all of the following: Provisional Practice Application Form Signed Monitoring Agreement 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 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) Evidence of successful completion of the written component of the Physiotherapy Competency Exam (PCE) Written evidence from the Alliance confirming that you are registered in the next available clinical component of the PCE The appropriate fees 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 Application Guide Section 1 Page 2 Page 11

12 PROVISIONAL PRACTICE APPLICATION FORM To apply for a Provisional Practice you must have passed the written component of the Physiotherapy Competency Examination (PCE) and be registered in the next available clinical component of the PCE. You must also have a job and a monitor. This category allows individuals to gain Physiotherapy experience while waiting to take the clinical component of the PCE. Members will be monitored through the Provisional Practice Monitoring Tool. 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: 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 Application Form Section 1 Page 3 Page 12

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 Level of Education: Baccalaureate Master Professional Doctorate Doctorate Level of Education: Baccalaureate Master Professional Doctorate Doctorate Name of Educational Institution: Name of Educational Institution: Name of Educational Institution: Province/State: Country: Year of Graduation: Province/State: Country: Year of Graduation: Province/State: Country: Year of Graduation: 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 *Field of Study Please use the applicable 3 letter code in the above section 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: 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 Application Form Section 1 Page 3 Page 13

14 Name of Educational Institution: Name of Educational Institution: Name of Educational Institution: Province/State: Province/State: Province/State: Country: Country: Country: Year of Graduation: Year of Graduation: Year of Graduation: 3.4 Educational Bridging Program Did you complete an Ontario Bridging Program for Internationally Educated Physiotherapists? Yes No If yes, what year: Where: Ryerson University University of Toronto 4. Information about the Physiotherapy Competency Exam To apply to become a Physiotherapy Resident you must have written and passed the Written Exam, part 1 of the Physiotherapy Competency Examination (PCE). Please provide the date when you wrote the exam: You must be registered in the next available sitting of the Clinical Exam (Part 2 of the PCE) The date of the Clinical Exam is: 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 to all locations, even if no professional licencing existed below. No Province/State Country Licence/Reg. No. Dates Provisional Practice Application Form Section 1 Page 3 Page 14

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 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 Application Form Section 1 Page 3 Page 15

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 Application Form Section 1 Page 3 Page 16

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 Country Province/State Postal Code/Zip Code Business Phone No. Ext. Fax No. Work Site #2 Name of Work Site Start Date Street Address City Country Province/State Postal Code/Zip Code Business Phone No. Ext. Fax No. Work Site #3 Name of Work Site Start Date Street Address City Country Province/State Postal Code/Zip Code Business Phone No. Ext. Fax No. Provisional Practice Application Form Section 1 Page 3 Page 17

18 Your Position Type Please choose only one per site. First Site Second Site Third Site Permanent Employee Temporary (Contract) Employee Casual Employee Employee (Other) Self-Employed 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 Provisional Practice Application Form Section 1 Page 3 Page 18

19 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 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? Please choose only one per site. Patient Care: First Site Second Site Third Site General Practice Sports Medicine Burns and Wound Management Plastics Amputations Orthopedics Rheumatology Provisional Practice Application Form Section 1 Page 3 Page 19

20 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 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 Other: Area of Practice Client Service Management/Case Management Consultation Administration Teaching (Physiotherapy entry-level) Physiotherapy-Related Continuing Education Teaching Other Teaching Quality Management Research Sales 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 Provisional Practice Application Form Section 1 Page 3 Page 20

21 Main Category of Patients Please choose only one per site. First Site Second Site Third Site All Ages Pediatric Adult Geriatric 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 Part-time Casual Not applicable Provisional Practice Application Form Section 1 Page 3 Page 21

22 10. Fees Please check the applicable amount in each section. Application Fees Fee Check Selection 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 Fee Check Selection Certificate of Registration Authorizing Provisional Practice $75.00 Credit card payment (Please note: the College of Physiotherapists of Ontario does not accept Visa Debit) Visa MasterCard Authorized payment amount: $ Card Number: 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 Application Form Section 1 Page 3 Page 22

23 12. Declaration To ensure my application for Provisional Practice registration is complete, I understand that I mustsign this declaration and check off the following three statements. I agree to the following: 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, or mail of any change to my address or phone number, and employment information within thirty days of the change occurring. I understand that I must notify the College immediately of any change to my Monitoring Agreement and get the change approved before I continue to practice. 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 Tel: ext. 222 Toll-free: ext. 222 By fax: By scanning and ing: registration@collegept.org Provisional Practice Application Form Section 1 Page 3 Page 23

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25 Provisional Practice MONITORING AGREEMENT To be completed with the Monitor and returned with the Resident s application for Provisional Practice. Note: Monitors must hold an Independent Practice certificate and have a minimum of 2 years practice experience. APPLICANT Applicant: Please check one of the following: This is my primary monitor. I am changing monitors. Proposed date of change: (mm/dd/yyyy): I am adding a monitor in addition to my primary monitor. Applicant Name Signature of Applicant Date (mm/dd/yyyy) MONITOR I agree to assume the role of Monitor for a Physiotherapy Resident, who is practicing under Provisional Practice. I agree to oversee the practice of this Resident. I understand that although I am not required to be onsite at all times when the Resident is engaged in patient care activities, the monitoring must be such that it allows me to be assured that the Resident can safely and competently carry out her/his clinical responsibilities. I understand that I am expected to monitor the Resident through activities which may include direct observation, case reviews, chart audits or discussions with other team members and meetings with the Resident. As part of my monitoring responsibilities, I agree to formally monitor the Resident using the Provisional Practice Monitoring Tool at the interim (if applicable) and the final phases of the Provisional Practice period. I agree to report to the Entry to Practice team, at the College of Physiotherapists of Ontario (within one business day) if the Resident has performed any act of professional misconduct, or of incompetence, or if the Physiotherapy Resident appears incapacitated. I will also immediately notify the Entry to Practice team, in writing if I am unable to fulfill my responsibility as Monitor to the Resident. I agree to provide follow-up information to the College of any concerns about the Resident identified in the monitoring process. I understand that this is a formal agreement and undertaking by myself and the College of Physiotherapists of Ontario. Monitor Name Monitor Registration Number Signature of Monitor Date (mm/dd/yyyy) Please return this form to the College, by using any of the three methods below. By scanning and ing: registration@collegept.org By fax: 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: ext. 222 or ext. 222 Provisional Practice Application Monitoring Agreement Section 1 Page 4 Page 25