Applicant and Mentor Details

Association of Chartered Physiotherapists in Sports Medicine

Applicant and Mentor Details
Applicant Details
Name: / Title: / DOB:
Contact address: / Email:
Tel:
Home:
Work:
Pre-registration Physiotherapy Education:
Institution:
Qualification:
Date obtained:
If you do not have a pre-registration qualification/are a ‘grandparented’ physiotherapist, please contact the CPD coordinator for more information how you will need to demonstrate the expected skills and experience.
CSP No:
ACPSM No:
HPC No: / Date Joined:
Date joined:
Date joined:
Mentor Details
(The physiotherapist(s) who is/are currently mentoring you in relation to advice, CPD, development planning etc.
You MUST place a X in the box to confirm that your mentor has reviewed this application
Name:
Address: / Position:
ACPSM level:
Email:
Tel:

Declaration: By submitting this application you are confirming that all information on the application is correct, you have read the relevant guidance documents and that your mentor has reviewed the application prior to submission.

Details of CPD plan
(Please refer to the guidance documents for more details)
Date started:
Summary of previous development areas and outcomes + current development plan need to be stated:
Emergency Care
First Aid
(Bronze)
Awarding Body:
Advanced sports trauma management
(Silver and Gold)
Awarding Body:
[Refer to guideline document for list of approved courses] / Date obtained:
Date obtained: / Certificate included:
Certificate included:
Employment History (Please give an overview of your employment history, please include dates, full time equivalent/hrs per week etc)
Employment History:
Details of shadowing and/or supervised clinical experience in sport (100 hours FTE)
Please note this does NOT include sole practice clinical experience, hours also listed in next section or experiences gained before qualifying as a physiotherapist.
Details of sport(type/training/comp) / Name of lead physiotherapist / Date (approximate) / Hours / What was learnt/observed
Details of clinical experience in sport
This can include sole practice or team working. It is expected that these hours are specific to the sporting environment and sporting context and not general clinic hours. Ensure no dates/hours overlap with any listed in the shadowing section.
Details of sport(type/training/comp/clinic) / Date range (approximate) / Hours
(approximate)
Courses (Please list your CPD courses you have undertaken, or a selection of the most relevant courses you have undertaken, include number of hours/days and a date. Include information relating to taping, exercise rehabilitation and soft tissue massage by the relevant sections and add other CPD below). If you are using M-level units please state unit name and relevant learning outcomes from the unit descriptor that demonstrate the type of CPD covered.
Taping CPD traditional taping CPD (required for Bronze):
Exercise/Functional Rehabilitation CPD (required for Silver):
Examples; strength and conditioning course, exercise principles/physiology, neuromuscular rehabilitation, planning rehabilitation programs etc
Soft Tissue Massage CPD (required for Silver):
Examples; ACPSEM massage course, Level 3 or 4 course, selection of 1 or 2 day soft tissue courses but must include massage.
Other Courses:
Course Reflection(copy this section as needed – 8 copies have been included in the form):
Course Title: / Date:
Key Learning Outcomes:
How you used this in your practice
Course Reflection (copy this section as needed – 8 copies have been included in the form):
Course Title: / Date:
Key Learning Outcomes:
How you used this in your practice
Course Reflection (copy this section as needed – 8 copies have been included in the form):
Course Title: / Date:
Key Learning Outcomes:
How you used this in your practice
Course Reflection (copy this section as needed – 8 copies have been included in the form):
Course Title: / Date:
Key Learning Outcomes:
How you used this in your practice
Course Reflection (copy this section as needed – 8 copies have been included in the form):
Course Title: / Date:
Key Learning Outcomes:
How you used this in your practice
Course Reflection (copy this section as needed – 8 copies have been included in the form):
Course Title: / Date:
Key Learning Outcomes:
How you used this in your practice
Course Reflection (copy this section as needed – 8 copies have been included in the form):
Course Title: / Date:
Key Learning Outcomes:
How you used this in your practice
Course Reflection (copy this section as needed – 8 copies have been included in the form):
Course Title: / Date:
Key Learning Outcomes:
How you used this in your practice
Critical Incident(Examples of situations where you have learned through reflection on your decisions relative to the outcome and how each incident changed your practice. Examples could involve experiences such as clinical assessment or treatment, communication, administration or management.)
(copy this section as needed – 4 copies have been included in the form):
Venue/environment: / Date:
Key incident:
What you might have done differently and why:
What you learned and how it changed your practice:
IFSPT Competency Number:
Critical Incident(Examples of situations where you have learned through reflection on your decisions relative to the outcome and how each incident changed your practice. Examples could involve experiences such as clinical assessment or treatment, communication, administration or management.)
(copy this section as needed – 4 copies have been included in the form):
Venue/environment: / Date:
Key incident:
What you might have done differently and why:
What you learned and how it changed your practice:
IFSPT Competency Number:
Critical Incident(Examples of situations where you have learned through reflection on your decisions relative to the outcome and how each incident changed your practice. Examples could involve experiences such as clinical assessment or treatment, communication, administration or management.)
(copy this section as needed – 4 copies have been included in the form):
Venue/environment: / Date:
Key incident:
What you might have done differently and why:
What you learned and how it changed your practice:
IFSPT Competency Number:
Critical Incident(Examples of situations where you have learned through reflection on your decisions relative to the outcome and how each incident changed your practice. Examples could involve experiences such as clinical assessment or treatment, communication, administration or management.)
(copy this section as needed – 4 copies have been included in the form):
Venue/environment: / Date:
Key incident:
What you might have done differently and why:
What you learned and how it changed your practice:
IFSPT Competency Number:
M level education/qualifications/publications/experience
( Gold level applicants only)
Supporting evidence will be required such as a case study, conference abstract or poster, publication reference, learning outcomes of the MSc programme attended providing evidence of sufficient breadth and depth of sports physiotherapy have been covered to comply with IFSPT recommendations. Reference can also be made back to examples of reflective practice detailed above.Must include the M-level unit name and the related learning outcomes from the unit specification for the specific competency.
Post-registration MSc programme:
Institution:
Date obtained:
Learning outcomes of programme and/or experiential learning related to IFSPT competencies:
Injury prevention:
Acute intervention:
Rehabilitation/ treatment:
Performance enhancement:
Promotion of a safe active lifestyle:
Professionalism and management:
Research involvement:
Dissemination of best practice:
Extending practice through innovation:
Promotion of fair play and anti-doping:
Mentorship details:
Evidence for role as a mentor, whether formal or informal.
Do not list the people acting as your mentor.
Mentee details
Name:
Address: / Position:
ACPSM level:
Email:
Tel:
Name:
Address: / Position:
ACPSM level:
Email:
Tel:
Name:
Address: / Position:
ACPSM level:
Email:
Tel: