2015 Accredited Exercise Physiologist (AEP) Application Form Only graduates who have graduated from a NUCAP (National University Course Accreditation Program) accredited exercise physiology university degree within the last 2 years are eligible to apply for exercise physiology accreditation. For a full list of NUCAP accredited university degrees please refer to www.essa.org.au/for universities/accredited NUCAP courses /full accreditation. If you have not graduated from a NUCAP accredited exercise physiology university degree within the last 2 years you are not eligible for exercise physiology accreditation. This application form is relevant for applicants applying in 2015. Please read this form in conjunction with the 2015 Accredited Exercise Physiologist Application Guide. General Please note the following requirements in order for your application to be assessed utilising this form: You must be a current exercise science/full member of Exercise & Sports Science Australia. It is a prerequisite for accreditation as an accredited exercise physiologist (AEP) that the candidate has a university degree from the field of exercise and sports science, has met all criteria and has become a current exercise science/full member of ESSA. An exercise science/full membership application may accompany this application. The exercise science/full membership application will be assessed before the AEP application. ESSA requires accredited exercise physiologists and sports scientists to maintain their accreditation through continuing professional development (CPD). 20 CPD points per calendar year (1 January 31 December) based on ESSA s CPD guidelines is required by all accredited exercise physiologists/accredited sports scientists. The only exceptions to this requirement are in the calendar year of first obtaining accreditation where there are no CPD requirements, or if accreditation is suspended in which case separate CPD requirements apply. Note: Standards and Compliance professional development must be completed within 4 months of the date of accreditation. You must have graduated from a NUCAP (National University Course Accreditation Program) accredited exercise physiology degree within the last 2 years. If this does not apply to you, unfortunately you are not eligible to apply. You must provide evidence of a minimum of 500 hours of practicum, meeting all practicum requirements. Applications will not be accepted by fax. Do not bind applications or provide the application in plastic sleeves/folders. Please secure with a bulldog (fold back) clip. Please allow 30 working days (from the date your complete application is received) for your application to be assessed and processed. ESSA assesses applications in order of arrival to the National Office. No applications will be fast-tracked, or assessed ahead of other applications. If further information is required to fully assess your application you will be provided the opportunity to submit further information within 1 month. An additional 30 working days will apply for your application to be re-assessed upon submission of the requested information. If the information is not received within 1 month the application will be deemed declined. A charge of $55.00 applies if your application is declined or if the request for further information is outstanding for more than 1 month. Please note: Applications will not be assessed until a complete application and supporting documentation has been received by the ESSA National Office. Once all points within the table below have been completed in full, send your application to: Exercise & Sports Science Australia (ESSA) Locked Bag 102 Albion DC QLD 4010 1
Please refer to the following table when completing your application to ensure your application is complete upon submission. ESSA will not assess incomplete applications. BEFORE SUBMITTING THIS APPLICATION FORM PLEASE READ AND COMPLETE THE FOLLOWING POINTS Are you a current exercise science member? Yes proceed with this form. No Complete the exercise science/full membership application form this application form can be downloaded from the ESSA website. Application page reference & attachments Tick when completed 1. Complete personal details (Section A). Page 3 2. Complete payment details (Section B). Include accreditation fee payment of $340.00 including GST. Either complete the credit card details or attach a cheque or money order made payable to Exercise & Sports Science Australia. Please note: credit card payments incur a merchant fee of 1.5% of the quoted fees. Please also ensure your exercise science/full membership is current. If not, you are able to renew online or contact the ESSA National Office. Page 5 3. Complete professional declarations (Section C). Page 5 4. List university qualifications achieved (Section D). Page 6 5a. Provide photocopies of official and final academic transcript/s. Photocopies must be signed and certified as true copies by a Justice of the Peace or notary. ATTACH TO APPLICATION Provide a letter of university degree completion if required. 5b. Attach Certificate of Completion for the ESSA Standards & Compliance Professional Development (if applicable). 6. Provide current resume. ATTACH TO APPLICATION 7. Supply evidence for first aid (HLTFA311A First Aid or HLTAID003 Provide First Aid) and CPR (HLTAID001 Provide Cardiopulmonary Resuscitation). Please ensure that your first aid and CPR statement of attainment/s are valid for at least 45 days on submission of your application. 8. Practicum summary table (Section E). Complete the practicum summary table and total your hours for each category. ATTACH Statement/s of attainment TO APPLICATION Page 6 9. Complete statutory declaration (Section F). Page 7 10. Practicum evidence (Word versions of the following documents are available on the Application webpage). Page 8 i) Complete the clinical practicum reference form for apparently healthy practicum. Page 8 attach this to the apparently healthy logbook ii) Complete the clinical practicum reference form for cardiopulmonary/metabolic practicum. iii) Complete the clinical practicum reference form for musculoskeletal/neurological/neuromuscular practicum. iv) Complete the clinical practicum reference form for other clinical health delivery practicum. vi) Logbooks. Examples of how to complete the logbooks can be found in the 2015 accredited exercise physiologist application guide. Word versions are available on the Application webpage Page 9 attach this to the cardiopulmonary/metabolic logbook Page 11 attach this to the musculoskeletal/neurological/ neuromuscular logbook Page 13 attach this to the other clinical health delivery logbook (if required) Page 14 2
Accredited Exercise Physiologist Application Form only applicants who have graduated from a NUCAP accredited exercise physiology degree within the last 2 years are eligible to apply Section A Personal details Title Given Names Surname Email DOB *This is required for your website login Are you of Aboriginal or Torres Strait Islander origin? Yes No How did you find out about ESSA AEP accreditation? ESSA website Colleague Employer University Other Postal address Address Town/Suburb State Postcode Phone Fax Work address and employment information Address Town/Suburb State Postcode Phone Fax Mobile Current employment Previous position/title Please indicate your primary, and if applicable your secondary, work sector by placing a 1 (for primary area of employment) and 2 (for secondary area of employment if applicable) in the boxes provided: Federal government organisation Research/education institution Sporting club/institution State government organisation Fitness club/institution Health care organisation Hospital Mining Private company Sporting club/institution Workers compensation agency Student Not currently working On leave 3
Please indicate your primary, and if applicable your secondary, area of employment by placing a 1 (for primary area of employment) and 2 (for secondary area of employment if applicable) in the boxes provided: Administration/project officer Aged care Chronic disease management Chronic disease prevention Clinical assessments & screening Coaching & athlete development Community health/health promotion Education Fitness industry Hospital Management Occupational health & assessment Rehabilitation case management Rehabilitation service provider Sports science testing Strength & conditioning Workplace health or corporate health Please indicate your primary, and if applicable your secondary, specialty by placing a 1 (for primary area of employment) and 2 (for secondary area of employment if applicable) in the boxes provided: Paediatrics Musculoskeletal Cardiac Metabolic Neurologic Cancer Primary prevention Mental health Ergonomics Sport enhancement Older adults Disability services Testing/screening Other Please indicate languages you are fluent in by placing a tick in the boxes provided: English Greek Cantonese Arabic Vietnamese Italian German Mandarin Spanish Tagalog Croatian Polish Maltese Turkish Netherlandic French Japanese Privacy Consent I acknowledge that ESSA is obliged to observe the strict privacy rules in the Privacy Amendment Act (2012) and that for ESSA to support its AEPs, ESSA sometimes needs to provide contact details about me to people who are accessing services and/or providing funded health services. By taking accreditation, I consent for my work details, including my full name, business company or trading name, address and place of business and contact details to be disclosed on the ESSA website search function, and for those details to be provided to the National Health Services Directory, Medicare Australia, Department of Veterans Affairs, workers compensation authorities and health funds. I also give my consent for ESSA to confirm my accreditation details with the above bodies if needed. 4
Section B Payment details Cheque or money order made payable to Exercise & Sports Science Australia is attached OR Card type (Please select) VISA Mastercard Cardholder s name Expiry of card / (month/year) Card number By submitting this application I authorise the following: Exercise & Sports Science Australia will debit my credit card for the amount of $55.00 including GST plus a 1.5% merchant fee upon receipt of my application in order for the application to be assessed Exercise & Sports Science Australia will debit a further $285.00 plus a 1.5% merchant fee. Yes No By submitting this application I acknowledge that Exercise & Sports Science Australia will debit my credit card for the amount of $55.00 plus a 1.5% merchant fee (non-refundable) should the application be declined or if the request for further information is outstanding for more than 1 month. Signature Date Section C - Professional declarations Declaration I certify that the information supplied on and with this form, and any additional information supplied, is true and correct. Applicant s signature Date If accepted by the association as an accredited exercise physiologist I agree to abide by the ESSA Code of Professional Conduct and Ethical Practice. Applicant s signature Date If accepted by the association as an accredited exercise physiologist I will maintain current professional indemnity, public liability insurance, first aid and cardiopulmonary resuscitation (CPR) qualifications. Applicant s signature Date If accepted by the association as an accredited exercise physiologist I agree to receive information and updates about ESSA and the industry and to have my services as an AEP searchable on the ESSA website. (note: you can change this at any time once you become accredited by logging into your profile in the members area of the website and removing yourself from the search function) Applicant s signature Date 5
Section D University qualifications achieved I have completed the following university qualifications: University Degree Code University Year completed Total years full time equivalent study Attach a certified photocopy of your final academic transcript. A final academic transcript shows successful course completion or conferral. Attach a photocopy of the Certificate of Completion for the ESSA Standards and Compliance Professional Development (if applicable). If you have not completed this prior to gaining AEP accreditation, you have 4 months from the date of accreditation to complete this compulsory professional development. Attach a copy of your current resume. Attach a copy of your First Aid and CPR statements of attainment. (HLTFA311A First Aid or HLTAID003 Provide First Aid) and CPR (HLTAID001 Provide Cardiopulmonary Resuscitation) Section E Practicum summary table Please complete the following table to indicate your practicum placements and hours undertaken. Please total your hours for each practicum category. 1 Practicum site Apparently healthy practicum (Minimum 140 hours) Cardiopulmonary/ metabolic practicum (Minimum 140 hours) Musculoskeletal/ neurological/neuro muscular practicum (Minimum 140 hours) Other clinical health delivery practicum (Maximum 80 hours) 2 3 4 5 6 7 8 9 10 Total Please ensure that your Clinical Logbook entries above total at least 360 hours 6
Section F Statutory declaration Commonwealth of Australia STATUTORY DECLARATION Statutory Declarations Act 1959 1 Insert the name, address and occupation of person making the declaration I, 1 (name), of (address) and of (occupation) make the following declaration under the Statutory Declarations Act 1959: 2 Set out matter declared to in numbered paragraphs 2 do solemnly and sincerely declare (2) that the attached documentation relating to my application to Exercise & Sports Science Australia (ESSA) for accreditation as an accredited exercise physiologist (AEP) is complete, accurate, truthful and supported by evidence. I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every particular. 3 Signature of person making the declaration 4 Place 5 Day 6 Month and year 3 Declared at 4 on 5 of 6 Before me, 7 Signature of person before whom the declaration is made (see over) 7 8 Full name, qualification and address of person before whom the declaration is made (in printed letters) 8 (qualification) of (address) (name) Note 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a term of 4 years see section 11 of the Statutory Declarations Act 1959. Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 see section 5A of the Statutory Declarations Act 1959. PLEASE REFER TO THE ACCREDITED EXERCISE PHYSIOLOGIST APPLICATION GUIDE FOR A LIST OF PEOPLE AUTHORISED TO WITNESS A STATUTORY DECLARATION. 7
i) Clinical practicum reference form Apparently healthy practicum A Word version of this form is available on the ESSA website under the membership section Reference for: Dear Colleague The above applicant has applied for accreditation with Exercise & Sports Science Australia (ESSA) as an accredited exercise physiologist (AEP). Requirements of this accreditation include a minimum of 140 hours practicum with apparently healthy clients. Please complete the following form based on your experience with the above applicant: Skills and experience In the following table, please confirm evidence of the practicum the applicant has gained in the relevant area of apparently healthy clients: (expand boxes where necessary) Breakdown of practicum hours (a minimum total of 140 hours) Total hours and dates* Evidence of specific roles and duties completed Site / Location Competent Not Competent Not able to comment Name and signature of referee Minimum of 60% (at least 84 hours) of face to face delivery i.e. Individualised/group delivery/instruction of an exercise program. *Testing/assessments without intent for prescription cannot be counted Maximum of 35% (up to 49 hours) for preparation for face to face delivery, observation and other activities related to the scope of practice of AEPs (healthy clients) Maximum of 5% (up to 7 hours) for administrative tasks Total hours at this practicum site hours face to face + hours preparation + hours administration Please note at least some of the hours of supervision within this category must be supervised by an AEP. Clinical supervisor: student ratios may be up to 1:5, with the proviso that there must be some 1:1 contact for each placement. Declaration: (To be completed by each referee listed in the table above) I certify that the information supplied is true and correct Signature Date Title Name Position and qualifications: I am a current AEP, ESSA ID# Phone Fax Email Please attach this form to apparently healthy practicum logbook 8
ii) Clinical practicum reference form Cardiopulmonary/metabolic practicum A Word version of this form is available on the ESSA website under the membership section Reference for: Dear Colleague The above applicant has applied for accreditation with Exercise & Sports Science Australia (ESSA) as an accredited exercise physiologist (AEP). Requirements of this accreditation include a minimum of 140 hours practical placements in the areas of cardiopulmonary/metabolic conditions. Please complete the following form based on your experience with the above applicant: Client exposure Please tick the types of clients the applicant has gained experience with: Metabolic Obesity Impaired glucose Dyslipidaemias Diabetes mellitis Cardiopulmonary Hypertension Asthma Coronary artery disease COPD Peripheral vascular disease Chronic heart failure Cystic fibrosis Other (please describe) Myocardial infarction Skills and experience In the following table, please confirm evidence of the clinical practice the applicant has gained in the relevant area of neuromuscular/neurological/musculoskeletal clients: (expand boxes where necessary) Breakdown of practicum hours (a minimum total of 140 hours) Total hours and dates* Evidence of specific roles and duties completed Site / Location Competent Not Competent Not able to comment Name and signature of referee Minimum of 60% (at least 84 hours) of face to face delivery i.e. Individualised/group delivery/instruction of an exercise program. *Testing/assessments without intent for prescription cannot be counted Maximum of 35% (up to 49 hours) for preparation for face to face delivery, observation and other activities related to the scope of practice of AEPs Maximum of 5% (up to 7 hours) for administrative tasks Total hours at this practicum site hours face to face + hours preparation + hours administration Please note at least some of the hours of supervision within this category must be supervised by an AEP. Clinical supervisor: student ratios may be up to 1:5, with the proviso that there must be some 1:1 contact for each placement. Declaration: (To be completed by each referee listed in the table above) I certify that the information supplied is true and correct Signature Date Title Name 9
Position and qualifications: I am a current AEP, ESSA ID# Phone Fax Email Please attach this form to cardiopulmonary/metabolic practicum logbook 10
iii) Clinical practicum reference form Musculoskeletal/neurological/neuromuscular practicum A Word version of this form is available on the ESSA website under the membership section Reference for: Dear Colleague The above applicant has applied for accreditation with Exercise & Sports Science Australia (ESSA) as an accredited exercise physiologist (AEP). Requirements of this accreditation include a minimum of 140 hours practicum in the area of musculoskeletal/neurological/ neuromuscular conditions. Please complete the following form based on your experience with the above applicant: Patient exposure Please tick the types of clients the applicant has gained experience with: Neurological / Neuromuscular Musculoskeletal Stroke (CVA) Multiple sclerosis (MS) Arthrides (esp. OA and RA) Other (please describe) Spinal cord injury (SCI) Other (please describe) Osteoporosis Acquired brain injury (ABI) Sub-acute and chronic specific and nonspecific musculoskeletal pain/injuries Skills and experience In the following table, please confirm evidence of the clinical practice the applicant has gained in the relevant area of neuromuscular/neurological/musculoskeletal clients: (expand boxes where necessary) Parkinson s disease Breakdown of practicum hours (a minimum total of 140 hours) Total hours and dates* Evidence of specific roles and duties completed Site / Location Competent Not Competent Not able to comment Name and signature of referee Minimum of 60% (at least 84 hours) of face to face delivery i.e. Individualised/group delivery/instruction of an exercise program. *Testing/assessments without intent for prescription cannot be counted Maximum of 35% (up to 49 hours) for preparation for face to face delivery, observation and other activities related to the scope of practice of AEPs Maximum of 5% (up to 7 hours) for administrative tasks Total hours at this practicum site hours face to face + hours preparation + hours administration Please note at least some of the hours of supervision within this category must be supervised by an AEP. Clinical supervisor: student ratios may be up to 1:5, with the proviso that there must be some 1:1 contact for each placement. Declaration: (To be completed by each referee listed in the table above) I certify that the information supplied is true and correct Signature Date Title Name 11
Position and qualifications: I am a current AEP, ESSA ID# Phone Fax Email Please attach this form to musculoskeletal/neurological/neuromuscular practicum logbook 12
iv) Clinical practicum reference form Other clinical health delivery practicum A Word version of this form is available on the ESSA website under the membership section Reference for: Dear Colleague The above applicant has applied for accreditation with Exercise & Sports Science Australia (ESSA) as an accredited exercise physiologist (AEP). Applicants may choose to participate in 80 hours supervised clinical placement of other health delivery. The activities approved under the 80 other clinical hours may occur in isolation (without a related exercise intervention). The other clinical hours can include: 1. Provision of exercise delivery for pathologies related to cancers, mental health, renal, or other pathologies: the purpose of this is to give students opportunities to strengthen their knowledge and develop competencies in these areas; 2. Diagnostic investigations or procedures (e.g. cardiac, pulmonary or other clinical investigations or procedures); 3. Health checks (e.g. point of care testing); 4. Job capacity assessments, functional capacity assessments; 5. Laboratory/research testing/screening (in isolation); 6. Case management; 7. Health promotion, health education or workplace health programs; 8. Other related clinical activities as described in the AEP generic and target pathology criteria (of the evidence based criteria table). Please complete the following form based on your experience with the above applicant: Skills and experience In the following table, please confirm evidence of the clinical practice the applicant has gained in the relevant area of other health delivery: (expand boxes where necessary) Total hours and dates* Evidence of specific roles and duties completed Site / location Competent Not Competent Not able to comment Name and signature of referee Total Hours *Clinical supervisor: student ratios may be up to 1:5, with the proviso that there must be some 1:1 contact for each placement. Declaration: (To be completed by each referee listed in the table above) I certify that the information supplied is true and correct Signature Date Title Name Position and qualifications: I am a current AEP, ESSA ID# Phone Fax Email Please attach this form to other clinical health delivery practicum logbook 13
v.) Logbook A Word version of the logbook templates are available on the ESSA website under the membership section Refer to the accredited exercise physiologist application guide for logbook examples. Make sure you print and attach logbooks to your application. Date Number of hours 1 Case description Description of services Supervisor name Supervisor s signature Applicant s signature 14