Member Application

Member Application Form

Thank you for applying to the Clinician Task Force! Please complete the following and email 2 references - 1 from a clinical source and 1 from the industry (a supplier or manufacturer), as we can only review full applications. Questions? Email admin@cliniciantaskforce.us
Name:*

First NameLast Name
Credentials:*
Email:*
example@example.com
Phone Number:*

Area CodePhone Number
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer name:*
Employer Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary work setting:
Healthcare Provider type:

Occupational TherapyPhysical TherapyRec TherapyNursePhysician/Physician AssistantOther
Certifications or describe 5 hours of CRT focused CEU in last 12 months:

ATPSMSBoth ATP & SMSOther
Member organizations:

APTAAOTAState OrganizationRESNAOther
Years of Practice in Seating and Mobility:
Years
The CTF's mission is "To provide clinical based expertise to inform and promote public policy, best practices, and positive outcomes regarding people with disabilities who require Complex Rehab Technology (CRT) products and related services". Do you agree to work for the mission of the CTF?

YesNoOther
Please read our mission statement again, and submit a brief personal statement describing your involvement, participation and experience in advocacy activities. Describe your clinical work with CRT, include your roles and how much of your clinical work has focused on seating and mobility. Explain why you would like to join the CTF. Let us know about any specific issues in seating and wheeled mobility that interest you related to advocacy, clinical practice, and/or educating novice therapists and/or students.
Do you agree to adhere to all legal standards and ethical norms? To commit to representing the perspective of a practicing clinician, participating in problem solving and decision making through a consensus group process, and abiding by professional standards of practice and code of ethics? (Furthermore, understand that you may choose to abstain from lending your support to a CTF initiative by contacting the Executive Director by email).

YesNoOther
CTF members meet in smaller workgroups to address focused issues. Each year you will have the opportunity to change the workgroup you work in. What workgroup(s) most interest you for this next year?

Federal: National-level topics that includes, but is not limited to, Medicare policies and coverage, DME MAC collaboration, federal legislation, and planning for and participation within national CRT events such as Roll on Capitol Hill and CRT Awareness Week. (Notable past projects: Telehealth resources)State Advocacy: This workgroup focuses on state level topics such as education of and awareness for Medicaid policies, intervening with Managed Medicaid issues, and identifying solutions for state specific coverage issues. (Notable past projects: resource of State Medicaid policy links)Clinical Coverage: This workgroup focuses on topics that impact clinical practice of CRT, such as coverage of CRT items.Education: This workgroup focuses on education for novice clinicians in seating and mobility and training future clinicians in academic programs in seating and mobility.
The minimum requirement for engagement as a CTF member is 1) attending the quarterly member meetings, and 2) providing 5 hours of volunteer work a year. This volunteer work is largely done within the workgroup. The CTF also desires to support members motivated to grow their leadership skills or provide services over 5 hours/year (Executive Board approved work may be eligible for hourly reimbursement over 5 hours). Please indicate the level of engagement you would like to participate at in the next year:

Involved: I will attend (or review recordings & minutes of) quarterly member meetings, attend workgroup meetings, and provide the 5 hours of volunteer work.Collaborate: I can meet the "involved" criteria, and also would like to work with an Executive Board approved project.Engaged: I can "collaborate", and would like to grow my leadership skills in this next year.Other
Help us stay up to date - please contact us if your employment, contact information, or ability to fulfill your obligations to the CTF changes in this next year.

I willI will notOther
As members of the CTF, the Executive Board has two additional requests:

First, to participate in annual fundraising efforts to sustain the mission of the CTF.

Second, to contact Congressional members as opportunities arise to support CTF advocacy efforts. In this, we ask you to share information and request support, seek support from your employment affiliations, and spearhead grassroots action at your facility and in your community.

Please complete your application by emailing 2 letters of reference - 1 from a clinical source and 1 from the industry (a supplier or manufacturer) - to admin@cliniciantaskforce.us

This submission affirms my commitment to actively participate in CTF activities, if approved as a member. I understand that I may withdraw my membership in the CTF at any time with written notice to the Executive Board.
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Member Application Form