Instructions for Individual Application Form

1. Detailed Course Description:
   A detailed explanation of the course and how this course directly relates to physical therapy practice, including how participation in the course should improve the clinical outcomes of the course participants.
2. Specific, Measurable Learning Objectives, Related to the Course Description:
   • Clearly written outcome objectives denoting the attitudes, knowledge, and/or skills that participants should attain by the conclusion of the course.
   • The objectives should directly tie back to the course description.
   • Due to the importance of evidence-based practice in health care professions, one of the objectives must refer to a review of current evidence.
   • There should be a minimum of three objectives for a course with 1-4 contact hours  or five objectives for a course with more than four contact hours.
3. Presenter(s) Credentials/Qualifications to Teach the Specific Course Material:
   • Full CVs (often several pages) are required to determine the qualifications of the primary course instructor(s). These CVs should specifically demonstrate why the particular presenter is qualified to teach this particular course.
   • Bio-sketch CVs (2-3 pages) are required for all other presenters, instructors, lab assistants, or another other such person involved with the educational process.
4. References:
   • There should be at least five references within the past 10 years, of which at least two references must be within the last five years. *
   • Recent references are important for providing participants with current knowledge.
   • References should follow a professional formatting style, such as AMA or APA style, so that all necessary information to verify the accuracy of the reference is possible, including page numbers.
   • For electronic resources, the same formatting style should apply; consumer websites are not acceptable as references.

   **EXCEPTION – All references for Indiana Jurisprudence courses must refer to the most recently published versions of Indiana’s statutes (Indiana Code) and Rules (Indiana Administrative Code), which can be found on the Indiana Board of Physical Therapy website.

5. Detailed Course Agenda/Schedule, Justifying the Requested Contact Hours:
   • For asynchronous courses, a detailed explanation of instructional methods (discussion boards, videos, tests, documents to read, etc.) with expected time to complete each learning module.
   • Contact Hours will not be awarded for activities that do not relate to the educational experience; this includes breaks, meals, registration, and course/instructor evaluation. These items should still appear on course agendas for clarity. If estimations are used for time to complete online or home study activities, a detailed explanation of how this time schedule was determined should be included.
6. Method for Verification of Attendance:
   (e.g., Participants sign in and initials out each day, and for each course or in a conference/symposium, with time of each signature; or for asynchronous courses, a record of time elapsed in a course.)
   • A sample sign-in/out sheet should be attached. If the course occurs over a meal break, then additional sign in/out columns should occur for the meal break.
   • For multiple days, multiple sign-in/outs will be required.
   • For multiple courses or modules, each distinct course or module requires its own sheet.
   • The participant needs only to sign in the first time, as all additional sign-ins/outs may be initials.
   • Each signature or initials must be time-stamped individually.
   • Short breaks (15 minutes or less) do not require signing in/out. If sign-in/out sheets are not being used, a detailed explanation of the process for recording attendance must be attached (with a sample, as applicable).
7. Sample Course and Instructor Evaluation Form:
   As feedback from the participant is important to assess whether the planned course objectives were met, a sample evaluation form is required.
8. Copy of Course Completion Certificate, with Room to Note APTA Indiana Approval Number:
   Required items on the completion certificate include:
   • Course Title
   • Number of Contact Hours
   • Course Sponsor
   • Course Instructor
   • Participant Name
   • APTA Indiana Approval Number
   • Course Date(s) of Attendance or Completion
   • Course Location (if applicable)

   Signature of the Instructor or Sponsor Designee

9. Method of Assessing Student Learning:
   Explain in detail how the instructor determined that learning objectives were met. Possible options include, but are not limited to:
   • Q&A Session
   • Post-test
   • Observation of Lab Practice.
   • For asynchronous courses, a copy of the post-test must be submitted.

If you do not have one or more of these items, you should be able to contact the course instructor or sponsor to request required items. Most instructors and sponsors are willing to provide these items to assist with the approval process. Many of these items can be found in the course brochure and handouts provided at the course. It is the responsibility of the applicant to provide this information. Course reviewers will not seek this information from the instructor or sponsor on behalf of the applicant.