Applicants Are Required to Provide Validation of Their Advanced Work History from Three

5. / SPECIALIST APPLICATION PART 5: VALIDATION OF ADVANCED PRACTICE
VALIDATION OF ADVANCED
PRACTICE FORM
This form supports the candidate’s application for registration within the specialist scope of practice: Physiotherapy Specialist /

Applicants are required to provide validation of their advanced work history from three nominated professional referees who can validate three periods of the applicant’s work experience. As the applicants are applying for recognition of their advanced level of knowledge, skills and contribution, it is expected that their nominated professional referees are well qualified to attest to their clinical expertise and advanced level of practice.

A / COMPLETING THIS FORM

Notes to referee:

The applicant has selected you as one of their referees because you have knowledge of their work history and advanced standard of physiotherapy practice.
This document should validate a period of your applicant’s employment history, provide evidence that they are able to practise physiotherapy at an advanced level in their particular area of specialty, and describe their knowledge, skills and contribution.
The applicant should be aware that an appropriate referee would be able to support the authenticity of their advanced clinical skills and knowledge, leadership, or contribution towards advancing scientific knowledge.

The Board may contact you as a referee to verify or clarify the information provided in this form.

B / PERSONAL DETAILS OF APPLICANT (TO BE COMPLETED BY APPLICANT)
Title: /  Miss /  Ms /  Mrs /  Mr /  Dr
Given Names:
Surname/Family Name:
Previous Name:
PTBNZ Registration Number: / 70 -
Job Title or Position:
Organisation & address:
City:
Country:
Phone Numbers: / Home: / ( ) / Mobile: / ( )
Work: / ( ) / Fax: / ( )
Email Address:
How long have you known the referee? / [ ] years [ ] months
How long have you worked with the referee? / [ ] years [ ] months
C / PERSONAL DETAILS OF REFEREE (TO BE COMPLETED BY REFEREE)
Title: /  Miss /  Ms /  Mrs /  Mr /  Dr
Given Names:
Surname/Family Name:
Health Practitioner Regulating Authority you are currently registered with (if any):
Registration Number:
Job title/Position:
Organisation and address
City:
Country:
Phone Numbers: / Home: / ( ) / Mobile: / ( )
Work: / ( ) / Fax: / ( )
Email Address:
D / APPLICANT INFORMATION (TO BE COMPLETED BY REFEREE)

The information you provide should verify that the applicant has demonstrated advanced knowledge and skills in his/her selected area of specialty.

It is helpful to describe the applicant’s work environment so the Board may place your information in context. Please complete all questions and if you have further information please continue on a separate sheet of paper.

Applicant’s job title or position:
Dates the applicant was employed in this position: / Commencement Date: / Day/Month/Year
Termination Date: / Day/Month/Year / Position is ongoing: 
The applicant was/is employed: / Full Time  / Hours per week: ______
Part Time  / Hours per week: ______
In what capacity is the applicant known to you?.
How long have you known the applicant? / [ ] years [ ] months
How long have you worked with the applicant? / [ ] years [ ] months
E / VALIDATION OF ADVANCED PRACTICE
Based on your personal knowledge of the applicant, please comment on their practice at an advanced level in one or more of the following areas:

Clinical practice
Contribution to Knowledge
Leadership

You could also include comment on the complexity of cases they have dealt with and how they have demonstrated advanced clinical reasoning.
F / APPLICANT INFORMATION (TO BE COMPLETED BY REFEREE)
To the best of your knowledge has the applicant been the subject of a disciplinary hearing resulting in an adverse outcome? / Yes [ ] No [ ]
If yes, please describe the nature of the disciplinary action, including the year and decision i.e. censure, conditions applied.
Please attach any relevant documents in support of this information
G / DECLARATION (TO BE COMPLETED BY REFEREE)
By making this declaration I hereby certify that:
I understand that making a false declaration is a criminal offence under section 172 of the Health Practitioner Competence Assurance Act 2003.
I understand that the Physiotherapy Board of New Zealand may obtain further information from me regarding the applicant.
The information that has been provided for this application is true and correct to the best of my knowledge.
Signature of referee: ______Date: Day/Month/Year
H / RETURN THIS FORM
Referees are to return this form directly to the Physiotherapy Board of New Zealand.
Post this form by air mail to:
The Registrar
The Physiotherapy Board of New Zealand
PO Box 10 734
Wellington 6143
NEW ZEALAND / Any further questions please contact the Board:
Telephone: / 0064 4 471 2610
Or Fax: / 0064 4 471 2613

Registration as a Physiotherapy Specialist: Validation of Advanced Practice Form July 2014Page 1