BY PLACING YOUR SIGNATURE BELOW, YOU ATTEST TO THE FOLLOWING:
I am a licensed Physical Therapist.
I have completed the required courses noted above.
I have passed the skills testing at each level of courses.
I have passed the written test after each level of courses by a grade of 70% or greater.
The case I am submitting is for a patient for whom I performed the complete examination, evaluation, diagnosis, prognosis, plan of care and interventions.
The case I am submitting is not fabricated or embellished.
This case represents my own work: gathering of references and authoring the case.
I have utilized the checklists, rubric, and “tips for authors” located on the Academy website to complete my case.
PRIOR to submitting this case reflection and application, I have worked for 1 year or longer with the respective population of patientswith:•CAPP Pelvic: Bladder, bowel, pelvic floor dysfunction, pelvic pain•CAPP OB: Dysfunction in pregnancyand first-year postpartum
I understand that my case will not be reviewed until ALL application items have been submitted.
The information in this application packet is true and accurate to the best of my knowledge.