This Pre-Authorization Form MUST be submitted prior to beginning clinical experience and the application process. NBSTSA CSFA Pre-Authorization for Clinical Experience Certified Surgical First Assistant (CSFA) Examination (For CSTs with Currency) The surgical first assistant candidate must demonstrate the listed proficiencies in 200 documented surgical procedures. (75 in general surgery, 75 in one specialty and 50 in any speciality). 1. Demonstrate the ability to apply advanced knowledge of normal and pathological surgical anatomy and physiology. 2. Demonstrate the ability to communicate the surgeon s preferences and specific patient s needs to the surgical team such as suture needs, specialty supplies and instrumentation and equipment. 3. Demonstrate the ability to provide preoperative skills such as assessing patient information, history, preoperative tests (EKG, EEG, EMG, lab values, diagnostic imaging), safety measures, biopsy results, positioning and draping. 4. Demonstrate the ability to provide intra-operative skills such visualization, trocar insertion, injection of local anesthetics, hemostasis, tissue handling, placement and securing of wound drains and closure of body planes. 5. Demonstrate the ability to provide postoperative skills in patient care such as dressing application, patient transfer and transport, transfer of care and monitoring for immediate complications. Candidates will be trained in these specific areas to ensure expertise of key job functions necessary for the duties of a surgical first assistant and will be provided with appropriate supervision in clinical experience. By entering this agreement, the expectations are that the participating facilities will provide all skills, training and assessment for the candidate s clinical experience. This is an agreement with The National Board of Surgical Technology and Surgical Assisting (NBSTSA) for the provision of surgical first assisting clinical site experience training opportunities. The following parties will take part in this agreement: CANDIDATE INFORMATION: Last Name, First (Legal name), Middle (PLEASE PRINT) Mailing Address (include apartment # if applicable) City State Zip Code Home Phone Number Work Phone Number Cell Number Social Security Number Email Secondary Email CST Certification Number DIRECTOR OF SURGERY INFORMATION: Director of Surgery (PLEASE PRINT) Facility/Institution Mailing Address (include apartment # if applicable) City State Zip Code Phone Number Fax Number Email Secondary Email Director of Surgery s Signature Date Candidate s Signature Date
2015 Certified Surgical First Assistant (CSFA) Examination Application INSTRUCTIONS: Please read entire application and complete fully. Allow 4-6 weeks for processing. If you have any questions, please contact the NBSTSA Certification Department directly at (800) 707-0057 or email questions to mail@nbstsa.org. Last Name, First (Legal name), Middle (PLEASE PRINT) Other Names You Have Used (please include copy of legal documentation to change name on file) Mailing Address (include apartment # if applicable) City State Zip Code Home Phone Number Work Phone Number Cell Number Social Security Number Certification Number Email Secondary Email Are you a national member of ASA/AST? q No q Yes, member number ELIGIBILITY OPTIONS: Check the appropriate eligibility level box. Incomplete applications will not be accepted. *Proof of graduation must include school name, date of graduation and type of degree received. Eligibility Option (please select one of the following and include all required documents): q Graduate of a CAAHEP accredited surgical first assistant program. School name: 4 Copy of diploma, transcript or notarized and signed letter from Program Director or registrar stating date of graduation from the surgical first assistant program and the type of degree received. q Currently certified as a CST through NBSTSA. 4 Pre-Authorization form for each sponsoring facility with evidence of malpractice coverage. (MUST be submitted PRIOR to clinical experience and application.) 4 Case logs demonstrating 200 cases (75 general surgery, 75 one speciality area, 50 any other speciality area). 4 Experience Verification form. Must be completed by Director of Surgery where cases were earned. q Current CSA (Certified Surgical Assistant) or SA-C (Surgical Assistant - Certified). 4 Proof of certification from either NSAA or ABSA. 4 50 continuing education credits in first assisting submitted on the CE reporting form. 4 Case logs demonstrating 200 cases (75 general surgery, 75 one speciality area, 50 any other speciality area). 4 Experience Verification form. Must be completed by Director of Surgery where cases were earned. q Graduate of a military surgical technology program. 4 Copy of diploma, DD214, or Smart Transcript (Must state the location of the military base where the program completed and the date of completion.) 4 Case logs demonstrating 200 cases (75 general surgery, 75 one speciality area, 50 any other speciality area). 4 Experience Verification form. Must be completed by Director of Surgery where cases were earned. TAPE COLOR PHOTO HERE 2x2 passport quality headshot photo (white background only) for certification card.
2015 CSFA Examination Application... Continued NBSTSA SPECIAL ACCOMMODATIONS: Are you requesting special testing arrangements due to physical impairment(s) or disability? q Yes q No If you are requesting special accommodations, you must include a comprehensive report from a qualified physician describing your disability and/or any other documentation which will assist in an informed decision by the NBSTSA regarding your request for accommodations as described in the Guidelines for Applying for Special Accommodations. Overseas testing: Are you requesting overseas testing? q Yes q No (If yes, please email NBSTSA at mail@nbstsa.org) FEES: AST/ASA members: Graduates/Students of approved surgical first assistant program $160. All others $190 Non-AST/ASA members: Graduates/Students of approved surgical first assistant program $260. All others $290 If you are a current CST, in addition to the CST/CSFA card/certificate, you can have a card/certificate with only CSFA on it for a $10 fee. Would you like CSFA-only documents? q Yes q No Important: The following fees are non-refundable: $60.00 processing fee (included in the examination fee) and $50.00 rush processing fee. q RUSH: Please rush my application. I ve enclosed the non-refundable $50 fee in addition to examination fees. Rush processing will process your application within 3-5 business days. Excludes mailing time to the candidate. Forms of Payment: q Money Order q Personal Check q Institutional Check q Visa q MasterCard *Please make checks payable to NBSTSA. Billing Address (only if different from applicant info) City State Zip Code $ Card Number Expiration Date Amount Charged Signature Name (as it appears on card) IMPORTANT: All applicants must sign the following statement: I do hereby acknowledge that all the information submitted in connection with my application to the certification program is true and correct to the best of my knowledge. I understand that falsified information on this application is grounds for denial of acceptance for examination or certification revocation, and may bar me from future certifications. I further acknowledge and agree that the NBSTSA may release my examination scores and credentialed status to state agencies in those states which regulate the practice of surgical first assisting, to accredited surgical first assisting education programs, NBSTSA recognized programmatic accreditation agencies and NBSTSA contracted vendors. Printed Name of Applicant Signature of Applicant Date IMPORTANT: All pre-graduate examination applicants must sign the following statement: I do hereby acknowledge as a pre-graduate examination candidate that proof of graduation MUST be submitted to the NBSTSA within 60 days of my actual examination date in order for my examination results to be released. Failure to produce graduation proof will result in invalidation of examination results and forfeiture of all examination fees. Printed Name of Applicant Signature of Applicant Date Would you like to receive other communication from the NBSTSA? q Yes q No Refund: The following fees are NON-REFUNDABLE: application processing fees ($60.00), RUSH processing fee ($50.00) and/or examination fee after the approval of the application and issuance of an Authorization to Test letter. RETURN THIS FORM, ALL NECESSARY DOCUMENTATION AND ENTIRE FEE TO: The National Board of Surgical Technology and Surgical Assisting, 6 West Dry Creek Circle, Suite 100, Littleton, CO 80120.
This Surgical Experience Verification Form MUST be submitted at the time of application for the CSFA examination. NBSTSA Surgical Experience Verification Form Certified Surgical First Assistant (CSFA) Examination (For CSTs with Currency, Military Candidates, CSAs and SA-Cs) IMPORTANT: Candidate MUST supply a Surgical Experience Verification form from the Director of Surgery. Candidate CANNOT fill out the verification form. The NBSTSA Surgical Experience Verification Form is valid for two years from the date it is notarized. CANDIDATE INFORMATION: Last Name, First (Legal name), Middle (PLEASE PRINT) Social Security Number CST Certification Number (if applicable) Signature Date SURGICAL FIRST ASSISTANT DEFINITION: As defined by the American College of Surgeons, the surgical first assistant provides aid in exposure, hemostasis and other technical functions that will help the surgeon carry out a safe operation with optimal results for the patient. This role will vary considerably with surgical procedure, specialty, and type of facility. EXAMINATION ELIGIBILITY: q CST with Currency, Current CSA or SA-C Candidates q Graduate of a military training surgical technology program Case logs demonstrating 200 cases (75 cases in general surgery, 75 cases in one speciality area and 50 cases in any speciality area). SECTION 1: Director of Surgery Instructions: This form must be filled out completely (no blanks). Complete all information in Section 1. Please print legibly in blue or black ink. Director of Surgery (PLEASE PRINT) Facility/Institution Mailing Address (include apartment # if applicable) City State Zip Code Phone Number Fax Number Email Applicant s Surgical First Assistant Experience Start Date (mm/dd/yyyy) Applicant s Surgical First Assistant Experience End Date (mm/dd/yyyy)
NBSTSA Surgical Experience Verification Form... Continued NBSTSA SECTION 11: (To be completed by the Director of Surgery named in Section 1) Instructions: Please check the items below which the applicant has accomplished. Candidate MUST function in the operating room at all times as the Primary Surgical First Assistant in the PRESENCE and under DIRECT observation of the Surgeon for the experience to be applicable to the examination eligibility requirements. Experience Verification (appropriate demonstration of): q Demonstrate the ability to apply advanced knowledge of normal and pathological surgical anatomy and physiology. q Demonstrate the ability to communicate the surgeon s preferences and specific patient s needs to the surgical team such as suture needs, specialty supplies and instrumentation and equipment. q Demonstrate the ability to provide preoperative skills such as assessing patient information, history, preoperative tests (EKG, EEG, EMG, lab values, diagnostic imaging), safety measures, biopsy results, positioning and draping. q Demonstrate the ability to provide intra-operative skills such as visualization, trocar insertion, injection of local anesthetics, hemostasis, tissue handling, placement and securing of wound drains and closure of body planes. q Demonstrate the ability to provide postoperative skills in patient care such as dressing application, patient transfer and transport, transfer of care and monitoring for immediate complications. Director of Surgery verification of work experience: q Yes, I verify that, to the best of my knowledge, this applicant s information about work experience at this facility is true. q No, The correct information is: Director of Surgery s Signature (Must be notarized) Date Last Name, First (Legal name), Middle (PLEASE PRINT) Job Title Phone Number
Surgical First Assistant Case Log For All Candidates PLEASE REFER TO CORE CURRICULUM FOR YOUR SPECIFIC EXAM. GENERAL Name: Date range: 200 CASES (list a minimum of 75 general surgery cases, 75 in one speciality area and 50 in any speciality area)