OccuPro. Certified Functional Capacity Evaluator. Application Packet

Transcription

1 OccuPro Certified Functional Capacity Evaluator Application Packet Certification Committee Page 1

2 Certification Application Form Name: Home Address: City: Professional Designation: Years in Profession: Degree: State: Zip: Year of Degree: Telephone: Institution: Secondary Degree: Year of Degree: Employer: Department: Address: City: Institution: Certifications: (Please include photocopy of diploma or transcripts from post secondary degrees) State: Zip: Telephone: Functional Capacity Evaluation Software Software you use: Functional Capacity Evaluation Training Course: Course Dates: Course Location: Offering Company: *If course was not offered by OccuPro please include course description and a copy of course completion certificate (Only Peer Reviewed Certification Process) Certification Committee Page 2

3 Professional Experience Form Please list up to three professional experiences related to your chosen profession and Functional Capacity Evaluation Employer: From: To: Location: Your Title: Supervisor: Title: Phone: Describe your duties including performing FCE s: Employer: From: To: Location: Your Title: Supervisor: Title: Phone: Describe your duties including performing FCE s: Employer: From: To: Location: Your Title: Supervisor: Title: Phone: Describe your duties including performing FCE s: Certification Committee Page 3

4 Statement of Professional Ethics and Practice I herby agree that I will uphold the certification in which I am being granted to the highest of respect and perform all of my Functional Capacity Evaluations in a manner that is consistent with all documented standards of practice. I certify that every evaluation that I perform will contain the standards of practice as set forth by the greater FCE community which includes performing safe, reliable, valid, and practical FCE s. I further recognize that as is in any health care field the evidence based aspect of performing FCE s is ever changing and that it is my responsibility over the course of this 4 year certification to continue to participate in course work that keeps me at the fore front of FCE performance. Signature: Print Name: Date: Certification Committee Page 4

5 Professional Reference Professional reference requested on behalf of: has received an application from the above named individual. This individual has applied for certification as a Certified Functional Capacity Evaluator. Your name has been submitted by the above named person as a client of said person. You have in some fashion utilized the above named persons Functional Capacity Evaluation services and/or have worked with this person in this capacity. OccuPro would appreciate your time in providing us with verification of the above named persons duties as a person who performs Functional Capacity Evaluation and if you could kindly answer the questions on the following page. Under the Information Practices Act, the information you provide in this document may be released, upon request, to the individual listed above. This information will not be released to the general public. We encourage you to be candid and forthright with your assessment of the above named person. Upon completion of this form and the questions on the following page please return both of these forms directly to: Certification Committee OccuPro Your Name: Address: City: Profession: Title: Employer: State: Zip: Telephone Number: Please describe your relationship with the applicant: Certification Committee Page 5

6 Functional Capacity Evaluations are tools used to determine a client s functional abilities for return to work purposes or for disability reasons. Please answer the following questions as it relates to the Functional Capacity Evaluations this applicant has performed for you as a customer of this applicant or with you if you were employed with the applicant. 1. Please include the number of Functional Capacity Evaluations this applicant has performed for you or within a practice you worked with the applicant? 2. Please provide a level of overall satisfaction in regards to the applicants Functional Capacity Evaluation Performance? 3. Please provide an overall level of Functional Capacity Evaluation competence displayed via documentation and report writing by the applicant? Not Competent Mildly Competent Competent Extremely Competent 4. Please provide an overall level of pre Functional Capacity Evaluation performance including ease of scheduling and communication? 5. Please provide an overall level of post Functional Capacity Evaluation performance including speed of report completion/delivery, follow up availability and professionalism? 6. How would you compare this Functional Capacity Evaluator compared to other FCE evaluators you work with? Poor Average Above Average Easily the best I use 7. The basic practice hierarchy for performing Functional Capacity Evaluations is Safety, Reliability, Validity, Practicality and Objectivity! Please describe how this functional capacity evaluator has demonstrated this in their FCE performance? 8. The Certification committee greatly appreciates your time and input! If you have any other positive comments or constructive criticism of this functional capacity evaluator or would like to add other thoughts on their abilities as they work to obtain this certification please add those below. Certification Committee Page 6

7 Professional Reference Professional reference requested on behalf of: has received an application from the above named individual. This individual has applied for certification as a Certified Functional Capacity Evaluator TM. Your name has been submitted by the above named person as a client of said person. You have in some fashion utilized the above named persons Functional Capacity Evaluation services and/or have worked with this person in this capacity. OccuPro would appreciate your time in providing us with verification of the above named persons duties as a person who performs Functional Capacity Evaluation and if you could kindly answer the questions on the following page. Under the Information Practices Act, the information you provide in this document may be released, upon request, to the individual listed above. This information will not be released to the general public. We encourage you to be candid and forthright with your assessment of the above named person. Upon completion of this form and the questions on the following page please return both of these forms directly to: Certification Committee OccuPro Your Name: Address: City: Profession: Title: Employer: State: Zip: Telephone Number: Please describe your relationship with the applicant: Certification Committee Page 7

8 Functional Capacity Evaluations are tools used to determine a client s functional abilities for return to work purposes or for disability reasons. Please answer the following questions as it relates to the Functional Capacity Evaluations this applicant has performed for you as a customer of this applicant or with you if you were employed with the applicant. 1. Please include the number of Functional Capacity Evaluations this applicant has performed for you or within a practice you worked with the applicant? 2. Please provide a level of overall satisfaction in regards to the applicants Functional Capacity Evaluation Performance? 3. Please provide an overall level of Functional Capacity Evaluation competence displayed via documentation and report writing by the applicant? Not Competent Mildly Competent Competent Extremely Competent 4. Please provide an overall level of pre Functional Capacity Evaluation performance including ease of scheduling and communication? 5. Please provide an overall level of post Functional Capacity Evaluation performance including speed of report completion/delivery, follow up availability and professionalism? 6. How would you compare this Functional Capacity Evaluator compared to other FCE evaluators you work with? Poor Average Above Average Easily the best I use 7. The basic practice hierarchy for performing Functional Capacity Evaluations is Safety, Reliability, Validity, Practicality and Objectivity! Please describe how this functional capacity evaluator has demonstrated this in their FCE performance? 8. The Certification committee greatly appreciates your time and input! If you have any other positive comments or constructive criticism of this functional capacity evaluator or would like to add other thoughts on their abilities as they work to obtain this certification please add those below. Certification Committee Page 8

9 Professional Reference Professional reference requested on behalf of: has received an application from the above named individual. This individual has applied for certification as a Certified Functional Capacity Evaluator TM. Your name has been submitted by the above named person as a client of said person. You have in some fashion utilized the above named persons Functional Capacity Evaluation services and/or have worked with this person in this capacity. OccuPro would appreciate your time in providing us with verification of the above named persons duties as a person who performs Functional Capacity Evaluation and if you could kindly answer the questions on the following page. Under the Information Practices Act, the information you provide in this document may be released, upon request, to the individual listed above. This information will not be released to the general public. We encourage you to be candid and forthright with your assessment of the above named person. Upon completion of this form and the questions on the following page please return both of these forms directly to: Certification Committee OccuPro Your Name: Address: City: Profession: Title: Employer: State: Zip: Telephone Number: Please describe your relationship with the applicant: Certification Committee Page 9

10 Functional Capacity Evaluations are tools used to determine a client s functional abilities for return to work purposes or for disability reasons. Please answer the following questions as it relates to the Functional Capacity Evaluations this applicant has performed for you as a customer of this applicant or with you if you were employed with the applicant. 1. Please include the number of Functional Capacity Evaluations this applicant has performed for you or within a practice you worked with the applicant? 2. Please provide a level of overall satisfaction in regards to the applicants Functional Capacity Evaluation Performance? 3. Please provide an overall level of Functional Capacity Evaluation competence displayed via documentation and report writing by the applicant? Not Competent Mildly Competent Competent Extremely Competent 4. Please provide an overall level of pre Functional Capacity Evaluation performance including ease of scheduling and communication? 5. Please provide an overall level of post Functional Capacity Evaluation performance including speed of report completion/delivery, follow up availability and professionalism? 6. How would you compare this Functional Capacity Evaluator compared to other FCE evaluators you work with? Poor Average Above Average Easily the best I use 7. The basic practice hierarchy for performing Functional Capacity Evaluations is Safety, Reliability, Validity, Practicality and Objectivity! Please describe how this functional capacity evaluator has demonstrated this in their FCE performance? 8. The Certification committee greatly appreciates your time and input! If you have any other positive comments or constructive criticism of this functional capacity evaluator or would like to add other thoughts on their abilities as they work to obtain this certification please add those below. Certification Committee Page 10

11 CFCE Report Submission Form Please list the 10 completed Functional Capacity Evaluations here. Client s Last Name Date of FCE Diagnosis Job Specific FCE Disability FCE OccuPro Use Only Submit these FCE s Comments or special considerations: Please note I plan on attending OccuPro s Advanced Functional Capacity Evaluation Training course and not participate in the peer reviewed process. *Please note you will still be required to submit your 4 FCE s to the certification committee but they will not be distributed to others. *Please note that you will not receive certification as a Certified Functional Capacity Evaluator by going through OccuPro s Advanced FCE course following your participation in someone else s basic FCE courses. If you participated in a different basic FCE course you need to go through the peer reviewed process for CFCE certification Certification Committee Page 11

12 CFCE Packet Completion Checklist Please initial next to the forms below indicating inclusion in this application packet. Please place this form as your cover letter when submitting this packet. Required Forms Initials Certification Application Form Copy of Allied Health Diploma or Transcripts Professional Experiences Form Statement of Professional Ethics and Practice Submission of all 3 Professional References List of 10 reports US $ for OccuPro trained evaluator doing peer reviewed process US $ for applicant taking OccuPro s Advanced FCE course US $ for Other Approved FCE Training *Please note that you must submit the three professional references to the professional references you choose and they need to be returned directly to OccuPro by the professional reference. If a professional reference is not returned to OccuPro by the professional reference a new professional reference will need to be submitted. Lastly, your application will not be sent to the committee for review until all three professional references are received. If OccuPro does not receive the professional reference within one month of your submission we will contact you to apprise you of the situation. Thank you again for working with OccuPro, the industry leader in Industrial Rehab software, continuing education and industrial rehab certification. Sincerely, The OccuPro Certification Committee Certification Committee Page 12