Application for Accreditation of
Residency Program

Thank you for your interest in applying for Residency Program Accreditation with NCOPE. In the course of filling out this application you'll need a few documents which you may want to prepare now for your convenience:

• Copies of any accreditation certificates or letters your organization has received from ABC or BOC
• Copies of any accreditation certificates or letters any affiliates have received from ABC or BOC
• Proof of O&P Professional Education for the program director and applicable staff (copy of diploma, transcripts and or certificates of completion of orthotic and or prosthetic coursework)
• Copies of the certificates issued at completion of NCOPE online Development Courses
• Copy of your organization's selection/admission procedure and the Residency Agreement

The Residency Application fee is $600. The add-on application fee to extend residency program accreditation to additional programs during a program's current three year cycle is $300. There is no fee for affiliate add-on. If you have any more questions please refer to "Tips" at the NCOPE website for additional, specific application requirements and contact information.

Application TypeRequired

Please tell us what kind of application you're interested in *

First-Time Applicant
Renewal
18-Month add-on
Orthotics add-on
Prosthetics add-on
Affiliate add-on

Organization Information

Please give us some basic information about your program. We'll use this information in identifying documents and to contact you.

Required
Please attach a copy of your accreditation certificate or accreditation confirmation letter from the accreditation agency.
Required
Please attach a copy of your accreditation certificate or accreditation confirmation letter from the accreditation agency.
Please attach a copy of your accreditation certificate or accreditation confirmation letter from the accreditation agency.
Orthotics Residency program (12-months)
Prosthetics Residency program (12-months)
Orthotics and Prosthetics Residency Program (18-months)
Plan to hire only one resident during accreditation cycle
Plan to hire two to three residents during accreditation cycle
Plan to hire residents every year (if funding is available) on a planned rotating
Required
Private Practice
College/University
Hospital/Clinic
Other
Required
Prosthetics Orthotics
Pediatrics (birth to 18)
Adult (18-55)
Geriatrics (>55)

If your facility/practice doesn't include one or more of the primary areas, please explain how the resident will gain exposure below: *

If your facility/practice doesn't include one or more of the primary areas, please explain how the resident will gain exposure below: *

If your facility/practice doesn't include one or more of the primary areas, please explain how the resident will gain exposure below: *

Identification of Prosthetic Procedures

Please indicate the number of times a resident in your program will be exposed to the following procedures using the number ranges provided. *

Required Prostheses or Care Resident's Exposure
Post-Operative Care
Syme and/or partial feet prosthesis
Transtibial prosthesis
Transfemoral prosthesis
Upper limb prosthesis
Since you marked 0 exposure opportunities for you'll need to be able to provide the resident appropriate exposure via an affiliation or assignment. Please indicate an appropriate affiliation in the "Affiliation" section below.

Recommended Experiences

Please indicate the number of times a resident in your program will be exposed to the following procedures using the number ranges provided. *

Recommended Prostheses or Care Resident's Exposure
Immediate post-operative prosthesis
Externally powered prosthesis
Various joint disarticulations

Prosthetic Facility Affiliations/Assignments for Residents

Please list all facilities where you have established affiliation or assigned a resident. Please note, all affiliation sites and mentors must meet the standards for a residency program.

Required
Please attach a copy of your accreditation certificate or accreditation confirmation letter from the accreditation agency.
Required
Please attach a copy of your accreditation certificate or accreditation confirmation letter from the accreditation agency.
Please attach a copy of your accreditation certificate or accreditation confirmation letter from the accreditation agency.

Identification of Orthotic Procedures/Experiences

Please indicate the number of times a resident in your program will be exposed to the following procedures and experiences using the number ranges provided. *

Required Orthoses Resident's Exposure
Ankle-foot orthosis
Cervical orthosis
Custom ankle-foot orthosis
Custom foot orthosis
Custom knee-ankle-foot orthosis
Custom scoliosis orthosis
Custom thoraco-lumbo-sacral orthosis
Foot orthosis
Hip orthosis
Knee-ankle-foot orthosis
Knee orthosis
Lumbo-sacral orthosis
Scoliosis orthosis
Thoraco-lumbo-sacral orthosis
Upper limb orthosis
Wrist-hand orthosis

Recommended Experiences

Please indicate the number of times a resident in your program will be exposed to the following procedures using the number ranges provided. *

Recommended Orthoses Resident's Exposure
Cervical-thoracic-lumbo-sacral orthosis
Footwear modifications
Fracture management
HALO
Hip-knee-ankle-foot orthosis
Seating systems
Shoulder-elbow orthosis
Standing frames
Wound care management

Orthotic Facility Affiliations/Assignments for Residents

Please list all facilities where you have established affiliation or assigned a resident. Please note, all affiliation sites and mentors must meet the standards for a residency program.

Required
Please attach a copy of your accreditation certificate or accreditation confirmation letter from the accreditation agency.
Required
Please attach a copy of your accreditation certificate or accreditation confirmation letter from the accreditation agency.
Please attach a copy of your accreditation certificate or accreditation confirmation letter from the accreditation agency.

Staff Information

Director

A residency program director must meet certain educational and experiential qualifications. Please reference Standard 4.1 for more information.

Required
Required
Required
Please attach proof of education. Proof must be provided. *
Required

Per NCOPE Standards of Accreditation for the Orthotics/Prosthetics Residency Program, completion of the NCOPE Residency Program Development Continuing Education Courses are required to be completed by both current and prospective NCOPE residency program directors and mentors. The current and prospective residency director must complete the “Course One: Preparation to be a Residency Program”, “Course Two: Development of a Residency Program” and “Course Three: Assessment in the Residency Program” courses. Please attach copies of these certificates of completion below.

Please attach certificates of completion(Course One). *
Please attach certificates of completion(Course Two). *
Please attach certificates of completion(Course Three). *

Please attach ACM Course.

Residency Program Staff

A residency program mentor must meet certain educational and experiential qualifications. Please reference Standard 4.2 for more information.

Required
Required
Required
Required
Required
Required
Please attach proof of education. Proof must be provided. *

Both current and prospective mentors at your residency program who evaluate and assess residents for competency utilizing the Typhon Group must also complete the "Course Two: Development of a Residency Program" and "Course Three: Assessment in the Residency Program" courses. Please include copies of these certificates of completion below, if applicable.

Please attach certificates of completion. *
Please attach certificates of completion. *

Required

For each practitioner to which this applies, you must provide an explanation. Please fill out the below fields for one practitioner at a time.

Required

Criminal History

In an effort to better serve the public trust, NCOPE reserves the right to perform a criminal history background check and to deny an application or make an accredited program’s status “inactive” based on the commission of a felony by the facility owners or residency program personnel.

Failure to provide accurate, true and correct information shall constitute grounds for denial of your application or an “inactive” status on a temporary or permanent basis.

Required
Required
Required
Required

You must submit the following with your application because you answered yes to one of the above questions.

• A complete written explanation of the circumstances surrounding the charge(s) that were files against such individual, which includes a narrative describing:

- A description of the incident
- Where the incident occurred
- That date the incident occurred
- The outcome of the charge(s) that were filed against the individual (e.g. verdict)
- Any penalty/sentence associated with charges that have been filed against the individual
- When the sentence was or will be completed
- Court case hearings regarding the incident

• Copies of court documents are also required. If the documents are not available, indicate the jurisdiction in which the charge(s), conviction of plea occurred and why the documents are not available.

• All application materials that are submitted are only released to NCOPE and its contractors and as required by law. The more information that you provide, the less time will be needed to review your eligibility status. If all appropriate information is not provided, the processing of your application will be delayed and your application will be considered incomplete. Incomplete applications will be returned to the sender. Application fees are non-refundable.

Please attach complete written description as described above.
Please attach copies of court documents as described above. *

Description of the Residency Program

Please provide answers and/or descriptions to the following questions on the proposed residency program

Orthotics:
Prosthetics
Dual
Required
Clinical lectures
Grand Rounds
Local Seminars
Manufacturing Workshops
National O&P Meetings
Regional/State Academic Meetings
Other

Does the program have written selection procedures, including admission eligitbility criteria to provide residents? *

Required
Please attach copy(ies) of the selection procedure/admission to residency program and the Resident Agreement (Standards 3.2 and 3.3).
Required
Required
Required
Required
Required
Required
Please attach a copy of full program Mission Statement *

(Time spent in all three areas of practice should be a combined total of 100%)

Clinical:
%
Fabrication:
%
Practice management (administrative):
%
Total:

(Specified settings should be a combined total of 100%)

Setting Orthotic Prosthetics
Primary facility % %
Affiliate facility % %
Speciality Clinic
(e.g. neuromuscular, cerebral palsy, spina bifida)
% %
Acute care hospital setting % %
Long-term rehabilitation Facility
(eg. nursing home, Assisted living facility)
% %
Other facility % %
Total
Fabricated Orthotic Prosthetics
Onsite % %
Outsourced % %
Orthotic Prosthetics
Upper Limb % %
Lower Limb % %
Spinal %
Cranial Facial %
Required
(Reference Standard 2.6.2)
Required
(Reference Standard 2.6.2)
Required
Required
Critically Assessed Topic (CAT)
Journal Club Presentation
Case Presentation
Professional in-service
Presentation at Grand Rounds, State, Regional, National or International Meeting
Critically Assessed/Appraised Topic (CAT) - A CAT is a brief summary of the most currently published research that is used to answer a specific clinical question. The CAT is a brief critical appraisal of the current literature. It may be used to inform clinical practice as a secondary knowledge source.
Journal Club Presentation ‐ A journal club discussion should occur with a minimum of five participants. These can be peers from your office, residents in the local area and/or other members of the rehab field outside of orthotics and prosthetics. A one page write‐up of the article and discussion must be uploaded to Typhon.
Case Presentation - A case presentation should be patient related. It should include patient evaluation, treatment plan, implementation of treatment plan and follow‐up. The case presentation should be given to an audience of peers and signed off by the Resident Director. Ideally this should be a case that is interesting and notable for some reason and requiring the use of a custom solution.
Professional In‐service - A professional in‐service does not have to be patient related. This can be given to a group of peers in the office, at a referral source’s office, physical therapy office, hospital or similar professional setting.
Presentation at Grand Rounds, State, Regional, National or International Meeting‐ Some residency sites closely tied to a hospital may attend Grand Rounds and you could present a case presentation or in‐service.
Literature Review
Case Study Involving Human Subjects
Scientific Study
Scientific Study Supervised by a Qualified Research Organization
Other Study
Internet accessibility
University library
In-house library
Release time to complete study
Instrumentation/specialty equipment on-site
Access to off site specialty equipment, i.e. gait lab

Please list any additional resources below

Terms of Residency Agreement

Required
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