*6f] Regional/State Academy Meetings D Other:

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1 DESC-ftJPTION OF THERESIDENCV;PROGRAM Pr~vide answers and/or descriptions to the fa liowing questions on the proposed residency program. 1. How many residents have completed your program in the past five years? a. First application for residency accreditation Ii] Residents Completed: b. Orthotic: c. Prosthetic: 2. Do you have auniversity affiliation? DYes D No If yes, identify: 3. Are you able to accommodate aresident seeking aclinical track residency experience? Ii] Yes D No (Reference Standard 2.6.2) 4. Are you able to accommodate aresident considering aresearch and Development residency track experience? DYes tj;lno ~ (Reference Standard 2.6.2) 5. Identify planned seminars/education experiences for the resident: [XI Clinical lectures D Grand Rounds f[i Local Seminars D Manufacturing Workshops Ii] National O&P Meetings *6f] Regional/State Academy Meetings D Other: 6. Which of the following and how many will assist as staff for the residency program? d. Administration: e. Clinicians:,---,,-, f. Technicians: --=-- ~ g. Certified Fitters: h. Certified CPed.: YJr 7. What is/will be the resident application process? i. Does the program have written selection procedures, including admission eligibility criteria to provide residents? t/i Yes D No If no, provide explanation: Submit with application acopy of the selection procedure/admission to residency program and the Resident Agreement. (Reference Standards 3.2 and 3.3).JfJ j. Do you require submission of aresume with cover letter? K1 Yes D No k. Do you perform an on-site interview? (ZI Yes D No I. Do you perform aphone interview? Iil Yes D No m. Do you have aset calendar day by which all residents must apply? D Yes Ii] No If yes, what is the date? n. Wi II the residency site pay the resident fee? IZ1 Yes D No o. What are the transportation requirement(s) of the residents to participate at the proposed residency program? p. Do you require the residents to sign anon-compete contract? [[] Yes D No q. Will trlere be times when aresident is supervised directly via live video, web cam, or by other means of live visual technology? In space below provide detail. NA r. In space below provide The Program's Mission Statement. THE PROGRAM MUST HAVE AMISSION STATEMENT THAT DESCRIBES THE OVERALL PURPOSE(S) OF THE RESIDENCY PROGRAM ~.LL.~ s. In space below provide any additional information on the application process of residents for the proposed program: continues» NCOPE APPLICATION FOR ACCREDITATION OF RESIDENCY PROGRAM 7

2 Mission Statement - Northern Prosthetics The Mission of Northern Prosthetics residency program is to expose our residents to the best quality prosthetic/orthotic care in the state. Residents will gain the necessary experience and exposure to become qualified entry level clinicians through the collaborative efforts and expertise of our qualified clinicians while addressing the concerns and opinions of the patient, treating not just the deficiency or dysfunction, but the patient as a whole to ensure the best functional outcome for our patients.

3 Provide answers and/or descriptions to the following questions on the proposed residency program. 8. What is the expected percentc\ge of lime spent by the resident in the following areas of the practice: q. Clinical: Time spent in the three areas r. Fabrication: 45 should be a combined total of 100 s. Practice management (administrative): Identify the percentage of time in the specific setting that direct patient care is provided by the practice: Setting Primary facility: Affiliate facility: Specialty clinic: (e.g., neuromuscular, cerebral palsy, spina bifida) Acute care hospital setting: Orthotics 85...l.L ,--...:::5 Settings for each discipline should be a combined total of 100 Prosthetics Long-term rehabilitation Facility: --~_ (e.g., nursing home, Assisted living facility) Other facility: ---=--_ Identify the percentc\ge of devices fabricated on-site at the residency site and outsourced to central: Fabricated Orthotic Prosthetic ~ Onsite: 90 OutsoLirced: 11. Identify the percentage of devices which incorporates the use of CAD/CAM in the practice. Orthotic Prosthetic Upper limb Upper limb Lower limb o Lower limb Spinal ---"'-- Cranial Facial Does this practice participate in any specialty clinic affiliations? Check all that apply: FREOUENCY FREQUENCY o Management of spine o CP Clinic Spine (post-operative) [ij Wound Care weekly o Brain Injury o Muscular Dystrophy o Burns o Pediatric Orthopedic o Scoliosis Hand Clinic [] Diabetic/Neuropathic foot o Amputee Clinic OSpina Bifida o Sports Medicine [] Veterans o Pedorthotic o Indigent care outreach Gait o MS Clinics o Cranial Facial o Shriners Hospital o Upper Identify specialty clinics not listed: continues» NCOPE APPLICATION FOR ACCREDITATION OF RESIDENCY PROGRAM 8

4 Provide answers and/or descriptions to the following questions on the proposed residency program. 13. Will the resident have the opportunity to observe surgical procedures? [] Yes 0 No ~ 14. Please identify types of activities you anticipate a"clinical Track" resident can complete from the checklist below. 1[1 Critically Assessed Topic (CAT) 0 Journal Club presentation KJ Case Presentation [] Professional in-service 1Xl Presentation at grand rounds, state, regional, national or international meeting CRITICALLY ASSESSED (APPRAISED) TOPIC (CAT) - ACAT is abrief summary of the most currently published research that is used to answer aspecific clinical question. The author defines the scope of the CAT based on his/her knowledge of the topic and research at hand. The CAT is abrief critical appraisal of the literature. It may be used to inform clinical practice as asecondary knowledge source. CASE PRESENTATION Acase study presentation given to colleagues within the residency program. Acase study involves aparticular method of research. Rather than using large samples and following arigid protocol to examine alimited number of variables, case study methods involve an in-depth, longitudinal examination of a Single instance or event. Case studies lend themselves especially to generating (rather than testing) hypotheses. IN-SERVICE Apresentation on atopic related to O&P given to agroup of professionals at alocal hospital, nursing facility, physical therapy office, or similar, with the intention of increasing the knowledge level of the attendees on the specific O&P topic. 15. Please identify types of directed studies you anticipate a"research and Development Track" resident to complete from the checklist below. Literature Review 0 Case Study Involving Human Subjects 0 Scientific Study ~ 0 Scientific Study Supervised by aqualified Research Organization 0 Other Study LITERATURE REVIEW - A literature review is acompilation and analysis of published literature from journals, books, and conference proceedings. Its purpose is to determine the state-ol-the-art or the state-of-the-science in an area. Case Study Involving Human Subjects - If the procedures performed on the subjects involve routine measurements and treatments typical for apatient presenting with the given diagnosis, and the patient is not required to do anything that departs from normal routines for this diagnosis (i.e., activities involved in the research are those that the patient and practitioner would normally be involved in anyway), and is not part of an experiment, then the Residency Directed Study might be considered a Case Study. SCIENTIFIC STUDY - AResidency Directed Study that involves the development and testing of ahypothesis is ascientific Study This includes any study in which one or more of the following criteria are met: 1.} two or more samples or subjects are compared; 2.) before-and-after data are compared (other than acase study); 3.) outcomes are defined by measures of the extent to which "success" or "failure" occur (other than acase study); 4.) data obtained from experiments are evaluated in some manner, including comparison to theoretical predictions; 5.) data are taken from patient liles for purposes 01 analysis (other than acase study); 6.) ascientific theory is examined or proposed; or 7.) asurvey is administered and the results reported. Studies in which it is planned in advance that subjects will receive treatments involving the use of two or more different components or designs for the purpose of evaluating or comparing the components or designs is ascientific Study. SCIENTIFIC STUDY SUPERVISED BY AQUALIFIED RESEARCH ORGANIZATION If aresident is conducting the research project to fulfill requirements for amasters or doctorate degree, or is undertaking the research project as part 01 aresearch effort under the supervision of a university, teaching or research hospital, clinic, or other qualified organization, and the activity is subject to review by an Institutional Review Board (lrb) for human subjects, or aresearch advisory committee, then the study qualifies as ascientific Study Supervised by aqualified Research Organization. In such cases, the project usually will have aprincipal Investigator, who may be the Resident or someone who supervises the research project being undertaken by the Resident. OTHER STUDY There are anumber of research topics which do not fit clearly into the above categories. Examples are the development of patient information booklets, the design of patient assessment forms, and various kinds of business studies. These are collectively grouped under Other Study. continues }} NCOPE APPLICATION FOR ACCREDITATION OF RESIDENCY PROGRAM 9

5 DESCRIPTION. OFTHE 'REIIDENCY PRUGRAMtollt. Provide answers and/or descriptions to the following questions on the proposed residency program. 16. Identify all resources available for the resident to perform their directed study: a. Internet accessibility f[i b. University library Ii{] c. In-house library Iil d. Release time to complete study Iil e. Instrumentation/specialty equipment on-site 0 f. Access to off site specialty equipment, i.e., gait lab 0 Please list any additional resources not listed: Please mail application and payment to: National Commission on Orthotic and Prosthetic Education 330 John Carlyle St., Ste. 200 Alexandria, VA ext (fax) info@ncope.org FEE: $500 FOR FIRST TIME APPLICATION $400 FOR SITES APPLYING FOR REACCREDITATION $300 TO ADD ASINGLE DISCIPLINE Note: The review process can take up to 6weeks. Applicants who are not approved must reapply by submitting anew application. Application fee is non refundable. APPLICATION FOR ACCREDITATION OF ARESIDENCY PROGRAM CHECKLIST vj..ppiication is type(} or jjheck for application fee included ( Copy of ceruficate issued at completion on NCOPE online Development Course included Note: Applications can not be processed if certificate copy is not included with the application. NCOPE APPLICATION FOR ACCREDITA,JION OF RESIDENCY PROGRAM 10