RESPIRATORY THERAPY SOCIETY OF ONTARIO (RTSO) RESEARCH COMMITTEE ADVANCED PRACTICE EDUCATION AWARD APPLICATION

Transcription

1 RESPIRATORY THERAPY SOCIETY OF ONTARIO (RTSO) RESEARCH COMMITTEE ADVANCED PRACTICE EDUCATION AWARD APPLICATION The RTSO offers up to $5000 for an Anaesthesia Assistant Program educational grant from Abbvie Inc. and up to $1500 for all other courses of study to respiratory therapists who are members of the RTSO. Please complete this form using Arial 12-point, single-spaced, black font, unless otherwise indicated. This form and the Guidelines and Instructions for Advanced Practice Education Award can be downloaded from the RTSO website Please follow the guidelines to complete the form. If guidelines are not followed, applications may not be considered. ONE (1) electronic copy of the application is required. The electronic copy must be ed to Applications must meet the criteria identified in the Guidelines to be accepted for review. Applications must be RECEIVED by the RTSO by November 24 th to be reviewed by the Committee. Attention: Knowledge Translation Award 18 Wynford Dr., Suite 405 Toronto ON M3C 0K8 Telephone: (Toronto) Toll Free: SIGNATURES (All signatures must be present for application to be considered complete): By signing the page, successful applicants will indemnify and save harmless the Respiratory Therapy Society of Ontario from all actions, claims, suits, demands, liabilities, losses, damages, charges, costs or expenses (including legal fees) which may be imposed upon or incurred by or asserted against the Respiratory Therapy Society of Ontario by reason of or arising out of the funding of the proposed activity. _2017 Page 1 of 10

2 1. PERSONAL DATA Name: Address: Phone (Res): Phone (Bus): Address: Present Employer: Present Position: CRTO registration number: RTSO Member 2. COURSE OF STUDY FOR WHICH EDUCATION AWARD IS SOUGHT Course*: Institution: Duration of Program From Month/Year: To Month/Year: Amount of Tuition Fee: * Note: Applicants for Anaesthesia Assistant Programs will be considered for the Abbvie Anaesthesia Assistant Advanced Practice Award 3. SIGNATURE The undersigned agrees that the general conditions governing the award, as set forth in the "Guidelines for Applicants", apply to any Education Award made pursuant to this application and are hereby accepted by the applicant. Applicant: Date: Page 2 of 10

3 4. DESCRIPTION OF PROGRAM AND DOCUMENTATION OF ACCEPTANCE Provide a description of the course of study to be undertaken, i.e., course objectives, brief program description including clinical orientation as well as coursework. Append additional documentation confirming acceptance to the program as available. Note if application is submitted and the applicant hasn t received confirmation of acceptance, the applicant will not be considered as an awardee until documentation of acceptance to the program is provided. 5. SUMMARY OF EMPLOYMENT EXPERIENCE: Position and Major Responsibilities Employer Dates Employed Full-time/Parttime Page 3 of 10

4 6. EDUCATIONAL BACKGROUND: a) Degrees/diplomas/certifications b) In-service or professional organization programs attended in past year a) Degree/Diploma/Certifications Educational Institution/Agency Date of Completion b) In-service Attended in the past two years Organization Date(s) of Program c) Conferences/Professional Organization Programs Attended in the past two years Professional Organization and Title of Conference/Program Date/s of Conference/Program 7. PROFESSIONAL & VOLUNTEER CONTRIBUTIONS Provide a brief description of activities such as professional memberships and volunteer work, particularly as they relate to respiratory care. Include any awards or honours that you have received. Provide information about in-service presentations or workshops you have led or other demonstrations of workplace leadership. List any publications. a) Professional Memberships b) Volunteer Work Page 4 of 10

5 c) Awards or Honours d) In-service or Other Presentations including Workshop Facilitation, or Other Demonstrations of Leadership e) Publications (non-peer reviewed and peer reviewed publications including abstracts) in past five years 8. CAREER INTENT AND CONTRIBUTIONS TO RESPIRATORY CARE Describe 1) the relationship of the course of study to your career goals; 2) how this award will help you advance the practice of respiratory care; and 3) how the course relates to the vision and mission of The Respiratory Therapy Society of Ontario. Page 5 of 10

6 9. REFEREES Please give the names and addresses of the two referees you have contacted. Applicants are responsible for requesting referees to complete the enclosed form or write a letter of recommendation to the Chair, Research Committee of the RTSO. These letters, which should be given to the applicant in a sealed envelope, signed across the seal by the referee, must accompany your application. Referee 1: Address: Referee 2: Address: Note: A cover letter explaining why you wish to take or have taken this program should accompany your application form. Page 6 of 10

7 GUIDE FOR REFEREES OF THE RESPIRATORY THERAPY SOCIETY OF ONTARIO ADVANCED PRACTICE EDUCATION AWARD Please complete and return this form to the applicant in a sealed envelope, signed across the seal. The objective of the RTSO Advanced Practice Education Award is to support respiratory therapists in the pursuit of advanced knowledge and skills related to respiratory care. The course of study must involve a formal program with an evaluative component. Using this page, or in letter format, please address the following: 1. Name of Applicant: 2. Program in which enrolled/accepted: 3. Institution: 4. Relationship to the applicant (e.g., employment supervisor, academic supervisor, professor): 5. How long have you known the applicant? 6. Do you recommend him/her for RTSO Funding for an Education Award for Advanced Respiratory Practice? a. Yes No 7. Outline what you know of the applicant in regard to his/her ability to undertake an advanced practice program: Page 7 of 10

8 8. As you are able, please comment on the applicant s: a) Clinical Performance b) Focus on Respiratory Care c) Professional Contribution (e.g., in-service workshops/presentations/demonstrations of leadership) 9. Other Comments: Signature: Date: Your Name: Address: Phone: Fax: Address: Page 8 of 10

9 RESPIRATORY THERAPY SOCIETY OF ONTARIO ADVANCED PRACTICE EDUCATION AWARD APPLICATION CHECKLIST Complete in duplicate. Retain one copy and submit one with your application. Office Applicant 1. Basic Criteria Met: RTSO Member Registered Respiratory Therapist in good standing with the CRTO Applied for/enrolled in Relevant Course of Study 2. Supplementary Information such as Program Description Enclosed 3. Cover Letter Enclosed 4. Application Enclosed 5. Letters of Reference Enclosed (signed across the seal): I. Name: Enclosed with application package: II. Name: Enclosed with application package: 6. Send 1 and 1 Completed Copy, including appendices Submit to: Respiratory Therapy Society of Ontario Research Committee 18 Wynford Dr., Suite 405 Toronto ON M3C 0K8 By to: office@rtso.ca Page 9 of 10

10 Name: Address: Phone (Res): Phone (Bus): Fax: Address: RESPIRATORY THERAPY SOCIETY OF ONTARIO ADVANCED PRACTICE EDUCATION AWARD FINAL REPORT Submit this form within six months of completion of the course of study Course of Study Completed: Educational Institute: Date of Complete of Program: Current Employment: How is the program relevant in your practice today? What are your future plans to use the knowledge and skills you gained in the program? Signature of Applicant: Date: Submit to: Chair, Respiratory Therapy Society of Ontario Research Committee Respiratory Therapy Society of Ontario 18 Wynford Dr., Suite 405 Toronto ON M3C 0K8 Or send report by to: Page 10 of 10