Con Ed# ______

!!ATTENTION!!
Please read this application in its entirety prior to sending it to CPTA for review.

Before sending this application for review, ask yourself the following questions. If you find yourself answering no to any of them, then your application is not complete.

  • Have I included a sample of the actual course brochure/course announcement?
  • Does it include the course schedule?
  • Does it includethe objectives?
  • Does it includethe course description?
  • Does it include a short speaker bio?
  • Have I included the course bibliography/reference list?
  • Does it have a minimum of 5 references from within the last 5 years (2014 or more recent)?
  • Have I included a Resume forALL speaker(s)lab assistant(s)?
  • Do their Resumes list experience and knowledge related to the course?
  • Is each Resume submitted using the template included in the application, or in a similar format?
  • Is each Resume 10 pages or less?
  • Have I included a sample evaluation form?
  • Does it include the 5 required questions listed in the application?
  • Have I included a Certificate of Completion?
  • Does it include the required componentslisted in the application?
  • Mycourse contains a hands-on lab
  • Is the student-to-faculty ratio 16:1 or less?
  • Have I stated the ratio visibly on the course brochure?
  • We’re using clients/patients/attendees for a demonstration
  • Have I included the speaker(s)/assistant(s) license numbers?
  • Have I included a sampleinformed consent form?

Until all completed documents are received by CPTA,
the application will not be sent for review.

For questions regarding the Application Process or Processing Timeline, please visit our General Questions FAQ page on our website.

For questions regarding the Content of the Application and Definitions, please visit our Application Content FAQ page on our website.

If you have additional questions, please contact Kristy Murchison.

Continuing Education Course Approval Application - Provider

Application fee: $155 per course ($25 for District/SIG continuing education courses)
Applications must be submitted to the CPTA office at least one week prior to the start of the course, even if expedited service is requested.

**If submitting a conference with concurrent sessions for approval, each session must be submitted as a separate application. See page 4 for more details

Check off the following documents to be sure they are included with the application. Failure to include all requested documentation will result in the application being delayed or rejected. Please allow up to 60 days for processing.

1

Presenter qualifications (speakers AND lab assistants)using the resume template included in the application

Descriptive brochure or other method used to advertise the course, including course schedule and learning objectives

Course Bibliography

Participant evaluation form(including required components)Expedite Application (Additional $50)

Certificate of Completion (including required components) (48/72 Business Hour Response – See Restrictions Below)

Informed consent form (if patients/clients/attendees are being treated)

Revised 12/13/18

Section 1: Provider Information
Provider name:
Contact person:
Mailing address:
City: State: ZIP Code:
Telephone: Fax:
Email address: Website:
Type of provider: District/SIG of CPTA APTA Hospital Individual Professional education provider
Education institution with an accredited PT/PTA program Other:
Section 2: Method of Payment
Visa MasterCard Discover AmEx Check made payable to CPTA
Name as it appears on credit card:
Credit card number: CVC#: Expiration date:
Credit card billing address:
City: State: Zip Code:
Signature of cardholder: Date:
Cardholder’s Email Address:
Section 3: Course Information
Title of Course:
Speaker(s) Name(s)(Do NOT write “See attached”; all speakers must be declared on this application) (Attach CVs/Resumes with degrees and licenses):
Lab Assistant(s) Name(s) in addition to Speaker(s) above(Do NOT write “See attached”; all lab assistants must be declared on this application)(Attach CVs/Resumes with degrees and licenses):
Date(s) of initial course (if self-study, indicate when course will first become available):
Location of initial course (city, state):
Type of course: Face-to-face Self-study Web-based seminar Audio conference Other:
Instructional level: Basic Intermediate Advanced
Proposed continuing education units:
(A detailed course schedule should be stated in your brochure/course announcement. The schedule will be used to verify contact hours and requested continuing education units)
Contact hours (excluding breaks, meal times, registration, and time set aside for evaluation): divided by 10 = CEU(s)
Tuition and/or fees:
Maximum Attendance:
Lab Information:
Will there be a lab? (A lab is anything in addition to lecture)
Yes (please complete this section) No (please continue to the next section)
What type of lab will be provided? Demonstration/Observation (the speaker will demonstrate a technique to attendees)
Hands-On/Technique (attendees will practice a technique)
If there is a hands-on/technique lab, please state the student to faculty ratio:1
(This ratio is calculated by dividing the maximum attendees allowed by the number of speakers plus lab assistants listed on the application. For all courses approved through the CPTA, the student to faculty ratio must be no greater than 16:1 if there is a hands-on lab component, including courses held outside of California.)
Direct Patient/Client/Attendee Treatment:
During the course, will patients, clients, or course attendees be used to demonstrate a treatment intervention or evaluation technique?
Yes No
(If yes, you must provide an Informed Consent Form/Liability Waiver to any person(s) being demonstrated upon. The consent form must state that the client/patient/attendee has the option to cease participation at any time during the presentation as well as state the name of the faculty member who will be demonstrating the treatment intervention. Attach a copy of the Informed Consent Form/Liability Waiver which will be given to patients/clients/attendees.)
If yes, the speaker(s) and lab assistant(s) performing the demonstration must hold an active license in their respective field, and it must be within the scope of their practice.
Please list below the type of license, state and license number forALL speakers and lab assistants who will be performing the demonstration, even if they are not licensed in California and whether or not they are a physical therapist or physical therapist assistant.
(California Practice Act Section 2630.5(c))
Name License Type State License #
Name License Type State License #
Name License Type State License #
Name License Type State License #
(if additional space is needed, please attach a separate sheet of paper)
Assessment Procedures:
Describe how the speaker(s) will assess whether the learning objectives have been met. Examples: Written test, observation of laboratory work, oral questions, etc.
Check if this course has been previously approved by CPTA (prior approval does not guarantee renewed approval)
CPTA approval number:
Check if this course has been approved by other organizations
List:
Section 4: Supporting Documentation
Speaker and Lab Assistant Qualifications
Attach aResume(using the resume templateafter page 6 or similar format)with the application for each speaker and lab assistant. Each CV/Resume or Statement of Qualification mustnot to exceed 10 pages in length.
The Resume should only include information that is relevant to the content of the course. It must include professional licenses, academic degrees, and work or teaching experience relevant to the course content. It should includeeducational institutions attended, credentials to teach the course, and relevant clinical experience.If applying for a self-study course, the author of the course must demonstrate expertise in the topic area.
Course Bibliography/Works Cited
The bibliography/works cited should consist of references that were used during the design phase of the course, or that maintain the currency of the content, and that support the content of the course. This is separate from a recommended reading list and works published by the author.
The bibliography must include a minimum of 5 works published within the last 5 years (2014 or more recent) and must include peer-reviewed articles. The bibliography must be legible. If the bibliography is presented on a PowerPoint slide, please retype in a word document.
Descriptive Brochure/Course Announcement
Attach a copy of the actual brochure or course announcement used to advertise the course. This may include a website, flyer, tri-fold brochure, or blast email.Course information typed in a word document is NOT acceptable. If the information is presented in a word document, the provider must demonstrate how the information is disseminated to the public i.e. attached in an email, as a PDF on a website, etc.
If the course is being advertised on a website, submit screenshots which show all of the required elements. Do not expect or assume your website will be seen during the review of your application. It is your responsibility to attach a brochure or screenshot.
The following information must be included in the brochure/course announcement:
  • Date and Location
  • Speaker names, titles, and a short statement of qualifications
  • Learning objectives (must be clearly written to identify the knowledge and skills the participants should acquire during the course)
  • Course description
  • Detailed course schedule outlining each portion of the course, including all breaks, meal times, and registration. For self-study courses, provide an outline of the average completion time for the course.
  • Type of instructional method(s) (lecture only, lecture w/demonstration, lecture w/hands-on/technique lab)
  • Student-to-faculty ratio (only necessary if course contains a hands-on/technique lab)
Course content must be easily recognizable as pertinent to the physical therapy profession and must be in the areas of clinical application; clinical management; clinical research; clinical, behavioral, or basic science; or professional ethics and practice management (includes federal and state law, risk management, documentation, and reimbursement).
Participant Evaluation Form
Course providers are required to allow attendees the opportunity to provide course feedback. Please attach a copy of your Participant Evaluation Form. Your evaluation form must contain the five questions listed below, as written:
  • Were the course objectives met?
  • Was evidence provided to substantiate material presented?
  • Were personal experience and observation the primary source of information?
  • Was a commercial product promoted?
  • If yes, did you feel that product promotion was the sole purpose of the course?
Following the completion of every course (whether or not the course is held in California, and whether or not PTs/PTAs are in attendance) providers are required to send a summary of the participants’ evaluations within 60 days.
Certificate of Completion
The PT Licensing Board of California requires all licensed PTs and PTAs to maintain a record of all continuing competency courses they complete. Please attach a copy of the Certificate of Completion. As per the PT Licensing Board of California, the following items are required to be stated on the Certificate of Completion for verification purposes.
  • Course Title
  • Course Provider Name
  • Course Date(s)
  • Number of CEUs or Contact Hours Earned
  • CPTA’s CEU Approval Number

Conferences/Symposiums with Concurrent Sessions
If you are submitting for a conference or symposium that has concurrent sessions (sessions that take place at the same time) and an attendee is unable to attend all sessions, each session is considered a separate course and must be submitted as its own application. For example, if you have a 2-day course with 25 sessions broken up into 5 time periods, and an attendee chooses one session per time period, you would submit 25 applications. The only exception is if the sessions are repeated during every time period so an attendee attends them all.

Courseproviders, speakers and lab assistants are prohibited from self-promotion of programs, products, and/or services during the presentation of the course.

By signing this application, I certify and understand that:

  • All information is true and correct.
  • All necessary documents are attached and contain all required components.
  • This course does not promote the use or sale of a commercial program, product or service.
  • If patients, clients, or attendees are being used to demonstrate a technique, ONLY the faculty member(s) with a current license(s) will provide treatment.
  • Following the completion of a course offering, or on a quarterly basis for self-study courses, a Summary of Evaluations will be submitted to the CPTA office.
  • CPTA has the right to revoke approval at any time if course information is found to be false, misleading, or inaccurate in any way; or if a course is found to promote the use or sale of a commercial program, product or service; or if a course provider fails to submit a Summary of Evaluations; or if course information is found to be changed from its original state after approval has been granted.

Signature Date

Application Process

  1. Application must be completed by the course provider. Provider is defined as the organization which processes payment for the course, manages registrations,issues credit to the participants, and completes the Summary of Evaluations.
  1. Applications can be submitted using one of the following methods:

Mail

Complete and mail one (1) copy of the application, requested documentationand payment to:

California Physical Therapy Association

1990 Del Paso Road

Sacramento, CA 95834

**IMPORTANT:If mailing your application, please do not use staples, paper clips, or post-it notes.

Fax

Complete and fax one (1) copy of the application, requested documentation and payment to (916) 646-5960.

Email

Complete and email the application and all requested documentation in a single pdf file and send to Kristy Murchison . If the file is too large to send in one pdf file, application may be split into two files.

**IMPORTANT:If emailing your application, leave the payment area BLANK. Our office will contact you to take payment over the phone.

  1. Once the application is received in the CPTA office, an initial screening will be conducted of the application to ensure completeness. If there are issues with the application or changes to be made, you will be contacted via email.
  1. Payment will be processed upon receipt in the CPTA office. No refunds will be issued once payment is processed, including in the event the application is denied.
  1. Once the application has been processed and deemed complete, it will be sent for review, the Review Committee has up to 30 business days to issue an initial response.Business days do not include weekends, holidays, or any day in which the CPTA office is closed.

***Expedited Applications: If you wish to expedite your application, please mark the box at the beginning of the application. Expedited applications will be reviewed within 2-3 business days.

  1. Expedited service is only available for the initial review. If an application is denied, the secondary review is subject to the normal denial process (stated below). Expedited service cannot be requested for the secondary review.

PLEASE NOTE:

  • CPTA Annual Conference will be October 11-13, 2019. During the weeks surrounding conference, response times may be extended to 45 days due to this busy time.
  • CPTA will be closed December 24, 2019to January 1, 2020. If any applications are received at CPTA during this time, they will not be processed until the office reopens.
  • The last date to submit an expedited application will be December 16, 2019 to ensure a timely response.

Approvals

If approved, your course approval will be valid for one year from the date of the first course offering. Approvals are valid at any location the course provideroffers the course as long as the content and speakers were approved in the original application.

You will be required to submit your Summary of Evaluations within 60 days following any course offering. Failure to submit your summary could result in future applications being denied.

Denials

If approval is denied, you will have 30 days to correct the application and submit additional materials, and it will be reconsidered. The CPTA will respond to the Course Provider within 30 business days from receipt of additional documentation. Reasons for denial may include but are not limited to:

  • Course material and/or learning objectives are not relevant to the field of Physical Therapy
  • The course promotes the use or sale of a commercial program, product, or service
  • Speaker(s) or lab assistant(s) not qualified to present course material
  • Speaker(s) or lab assistant(s) conducting a demonstration did not provide a valid license number
  • Student-to-faculty ratio is excessive when a hands-on/technique lab is being conducted
  • The bibliography does not provide sufficient, current evidence to support the course content
  • Requested documentation is missing from the application

Application Amendments

If a modification to the course title, speaker(s), lab assistant(s) or number of contact hours is needed, please download theCEU Amendment Application from our website and submit the new information with a $30 approval fee. Expedited service is available for an additional $50, and is subject to the same regulations listed under number four above.Amendments must be submitted at least one week prior to the course date for which they are needed.

Definitions

Course Provider: The course provider the organization which will be handling registration; marketing the course; administering course evaluations, consent forms and waivers; issuing CEU certificates; and maintaining course records for at least seven years.

Course Speaker: The person or persons who will be presenting the course content to the attendees.

Course Author: The person or persons that developed the content of the course. This may be the same person as the Course Speaker. A Course Author is most common for self-study courses.

Lab: Any part of a course that is in addition to a lecture.

Peer-reviewed Article: An article which appears in a professional, scientific journal that puts each manuscript through a process by which it is reviewed by peers (professional colleague with expertise in research and/or the content area related to the manuscript). These people read the manuscript carefully for content including research design, methodology (how the research was conducted), comparison to related literature, relevance to the profession and science, clarity, etc. The article must be approved by these people before it is accepted for publication.