Physical Therapist Learning Plan and Attestation Page Last:
First:
PTL License #:
After completing the Reflective Self-Assessment Tool (RSAT) and establishing learning goals, use this form to plan learning activities you will complete during the renewal cycle to accomplish your learning goals. Refer to the Board’s PDA List for details. Finalize this form before you renew your license. In the event of an audit, submit this finalized form and the required documentation for each completed activity. Before renewing your license, you must accrue 30 points; 15 points must be from Category I activities.
Learning Goal (copy here from the results of your RSAT)
CATEGORY I PDA __ Continuing education meeting Board’s Category I Standards (1 Contact hour = 1 point) __ Coursework from a regionally accredited college/university (10 points per credit hour) __ Coursework towards a transitional Doctor of Physical Therapy degree (10 points per credit hour) __ Completion of the online continuing competence learning and assessment tool oPTion administered by FSBPT, or another AKS preapproved by the Board (10 pointsmax 10 points in 10 year cycle) __ Completion of a residency or fellowship accredited through APTA (20 points) __ Completion of ABPTS specialist certification / recertification process (15 points) __ Completion of Induction Process for CDE Special Services License (10 points) __ Primary instructor in a Category I CE course (1/2 point per contact hour-max 5
points credit only for first delivery) __ “Read for Credit” in a professionally recognized peerreviewed journal-must include a testing component provided by the journal itself, e.g. JOSPT, JBJS, etc. (1 contact hour = 1 point with a max. of 10 points) CATEGORY II PDA __Coursework from a college/university not regionally accredited (5 points per credit hour) __ Continuing Education Courses not meeting Board’s Category I Standards (1 contact hour = ½ point) __ Primary instructor in a continuing education course that is not Category I (1/2 point per contact hour, max of 5 pointscredit only for first delivery) __ Workplace inservice attendance (1 contact hour = ½ point) __ Professional journal club with 3 or more attendees (1 contact hour = ½ point) __ Formal mentoring relationship (mentor or
protégé) (2 points) __ Read a scientific article or chapter in a professional book (1/2 point per article or chapter with a max of 2 points) __ CPR/ACLS/BLS or first aid certification or recertification (1 point) CATEGORY III PDA __ First author on a publication in a peer reviewed journal or textbook chapter (10 points) __ Secondary or senior author on a publication in a peer reviewed journal (5 points) __ Contribution to a research project (data collection, project development, consultation) (3 points) __ Grant reviewer (3 points) __ Journal article reviewer (3 points) __ Primary course coordinator teaching a course in an accredited physical therapy or a physical therapy assistant program (entry-level, post professional) or other healthcare program regulated by the State of Colorado (5 points per semester – credit only for first delivery) __ Guest instructor /
lecture/lab assisting in an accredited physical therapy or physical therapist assistant program or other healthcare program regulated by the State of Colorado (2 points per semester – credit only for first delivery) __ Serving as a Clinical Instructor to a physical therapist student or physical therapist assistant student (1 Point for every 40 hours with student) __ Speaker at a professional meeting (1 point per speaking hour with a max of 5 points-credit only for first delivery) __ Platform or Poster presentation or panel discussion member at a professional meeting (2 points-credit only for first delivery) __ Presenting a workplace in-service (1 point credit only for first delivery) __ Teaching in a nonprofessional / community setting (to members of the public) (1 point) __ Serving as a committee chair, Board member of office holder in a
professional organization related to physical therapy practice (responsibilities must go beyond committee membership (2 points) __ Community Service within the scope of profession (1 point=18 hours, 2 points=9-16 hours, 3 points=17-24 points, 4 points=25-32 points, max of 4 points) __ Serve as a subject matter expert/consultant (e.g. expert witness, licensure Board, insurance reviewer) (2 points) __ Organizational and program development activities (e.g. quality assurance programs, initial development of policies and procedures, outcomes database development) (2 points) __ National, state, district or Special Interest Group (SIG) business meetings of professional associations (1/2 point per contact hour) __ Peer to Peer learning activity (1 point)
Rev. 2/2017
Learning Goal (copy here from the results of your RSAT)
CATEGORY I PDA __ Continuing Education meeting Board’s Category I Standards (1 Contact hour = 1 point) __ Coursework from a regionally accredited college/university (10 points per credit hour) __ Coursework towards a transitional Doctor of Physical Therapy degree (10 points per credit hour) __ Completion of the online continuing competence learning and assessment tool oPTion administered by FSBPT, or another AKS preapproved by the Board (10 pointsmax 10 points in 10 year cycle) __ Completion of a residency or fellowship accredited through APTA (20 points) __ Completion of ABPTS specialist certification/recertifica tion process (15 point) __ Completion of Induction Process for CDE Special Services License (10 points) __ Primary instructor in a Category I CE course (1/2 point per contact hour-max 5 points credit only for
first delivery) __ “Read for Credit” in a professionally recognized peerreviewed journal-must include a testing component that is provided by the journal itself, e.g. JOSPT, JBJS, etc. (1 contact hour = 1 point with a max. of 10 points) CATEGORY II PDA __ Coursework from a college/university that is not regionally accredited (5 points per credit hour) __ Continuing Education Courses not meeting Board’s Standards (1 contact hour = ½ point) __ Primary instructor in a continuing education course that is not Category I (1/2 point per contact hour, max of 5 pointscredit only for first delivery) __ Workplace inservice attendance (1 contact hour = ½ point) __ Professional journal club with 3 or more attendees (1 contact hour = ½ point) __ Formal mentoring relationship (mentor or protégé) (2 points)
__ Read a scientific article or chapter in a professional book (1/2 point per article or chapter with a max of 2 points) __ CPR/ACLS/BLS or first aid certification or recertification (1 point) CATEGORY III PDA __ First author on a publication in a peer reviewed journal or textbook chapter (10 points) __ Secondary or senior author on a publication in a peer reviewed journal (5 points) __ Contribution to a research project (data collection, project development, consultation) (3 points) __ Grant reviewer (3 points) __ Journal article reviewer (3 points) __ Primary course coordinator teaching a course in an accredited physical therapy or a physical therapy assistant program (entry-level, post professional) or other healthcare program regulated by the State of Colorado (5 points per semester – credit only for first delivery) __ Guest instructor /
lecture/lab assisting in an accredited physical therapy or physical therapist assistant program or other healthcare program regulated by the State of Colorado (2 points per semester – credit only for first delivery) __ Serving as a Clinical Instructor to a physical therapist student or physical therapist assistant student (1 Point for every 40 hours with student) __ Speaker at a meeting (1 point per speaking hour with a max of 5 points-credit only for first delivery) __ Platform or Poster presentation or panel discussion member at a professional meeting (2 points-credit only for first delivery) __ Presenting a workplace in-service (1 point credit only for first delivery) __ Teaching in a nonprofessional /community setting (to members of the public) (1 point) __ Serving as a committee chair, Board member of office holder in a
professional organization related to physical therapy practice (responsibilities must go beyond committee membership (2 points) __ Community Service within the scope of profession (1 point=18 hours, 2 points=9-16 hours, 3 points=17-24 points, 4 points=25-32 points, max of 4 points) __ Serve as a subject matter expert/consultant (e.g. expert witness, licensure Board, insurance reviewer) (2 points) __ Organizational and program development activities (e.g. quality assurance programs, initial development of policies and procedures, outcomes database development) (2 points) __ National, state, district or Special Interest Group (SIG) business meetings of professional associations (1/2 point per contact hour) __ Peer to Peer learning activity (1 point)
If you create more than 2 Learning Goals, print additional Learning Plan forms and attach to this form. Attestation: This form serves as verification that I have completed the Reflective Self-Assessment Tool (RSAT) and created Learning Goals based on the results of the RSAT. I attest that the activities I completed will help me achieve the Learning Goals relevant to my advancement, experience, specialty, assessment outcomes, and/or practice. Signature_____________________________________________________
Date_________________________
Rev. 2/2017
