iii) Clinical Practicum Reference Forms Apparently Healthy Practicum
Reference for:
Dear Colleague,
The above applicant has applied for specialist accreditation by Exercise & Sports Science Australia (ESSA) as an exercise physiologist (AEP).
Requirements of this accreditation include a minimum of 140 hours practicum with apparently healthy clients.
Could you please complete the following form based on your experience with the above applicant:
Skills and Experience
In the following table, please provide evidence of the practicum you have gained in the relevant area of apparently healthy clients: (expand boxes where necessary)
Breakdown of Practicum hours (a minimum total of 140 hours)
Total hours and dates*
Evidence of specific roles and duties completed
Site / Location
Competent Not Competent Not able to comment
Name and signature of referee
Minimum of 60% (at least 84 hours) of face to face delivery i.e.
Individualised/group delivery/instruction of an exercise
program. *Testing/assessments without intent for prescription
cannot be counted
Exercise prescriptions for a range of healthy clients including running programs and for clients wanting to increase lean muscle.
√ P La Fleur
15 hours Instructed group sessions for boxing and pilates
√ P La Fleur
Maximum of 35% (up to 49 hours) for preparation for face to face delivery, observation and other activities related to the scope of
practice of AEPs
7 hours Program writing As above √ P La Fleur
9 hours Research √ P La Fleur
10 hours Observation of supervisor working with clients
√ P La Fleur
Maximum of 5% (up to 7 hours) for
administrative tasks 7 hours Filing and phone calls As above √ P La Fleur
Total hours at this prac site 193 hours 160 hours face to face + 26 hours preparation + 7 hours administration
*e.g. a) Testing sports teams without showing evidence of exercise programming will not be counted. B) An initial consultation involving demonstration of home based exercises will be accepted.
Declaration: (To be completed by each referee listed in the table above)
I certify that the information supplied is true and correct Signature Date
Title Name
Position and qualifications:): I am a current AEP, ESSA ID# __________
Peter La Fleur Mr
Director of Average Joe’s Gymnasium. Cert IV in fitness (PT College of Knowledge 2006), working as a personal trainer for 13 years.
Peter SMITH
P La Fleur 01/09/2013
Cardiopulmonary/metabolic clinical practicum reference form
Reference for:
Dear Colleague
The above applicant will be applying for accreditation with Exercise & Sports Science Australia (ESSA) as an accredited exercise physiologist (AEP). Requirements of this accreditation include a minimum of 140 hours of practical placements in the areas of cardiopulmonary/metabolic conditions.
Please complete the following form based on your experience with the above applicant:
Client exposure
Please tick the types of clients the applicant has gained experience with:
Metabolic Obesity Impaired glucose Dyslipidaemias Diabetes mellitis
Cardiopulmonary Hypertension Asthma Coronary artery disease COPD
Peripheral vascular
disease Cystic fibrosis Myocardial infarction
Chronic heart failure Other (please describe) Skills and experience
In the following table, please confirm evidence of the clinical practice the applicant has gained in the relevant area of neuromuscular/neurological/musculoskeletal clients: (expand boxes where necessary)
Breakdown of Practicum hours (a minimum total of 140 hours)
Total hours and dates*
Evidence of specific roles and duties completed
Site / Location
Competent Not Competent Not able to comment Name and signature of referee
Minimum of 60% (at least 84 hours) of face to face delivery i.e.
Individualised/group delivery/instruction of an exercise
program. *Testing/assessments without intent for prescription
cannot be counted
26/06/2013-30/08/2013
20 hours Pre and post cardiac rehab testing
Malibu Private Hospital
√ B/Roberts
90 hours Assisting with delivering group circuit based exercise sessions within clinic gym.
√ B/Roberts
5 hours Assisting with delivering one on one circuit based exercise sessions within clinic gym.
√ B/Roberts
Maximum of 35% (up to 49 hours) for preparation for face to face delivery, observation and other activities related to the scope of
practice of AEPs
15 hours Observation of the Physio & AEP delivering exercise sessions in clinic gym
As above
√ B/Roberts
7 hours
Research on pathologies, rehabilitation procedures post cardiac surgery and designing home exercise programs for patients who have completed the program.
√ B/Roberts
1 hour
Attended client education session on medication usage. This knowledge was applied to my face to face exercise delivery with clients.
√ B/Roberts
5 hours Case meeting to discuss patients’ progress through program.
√ B/Roberts
Maximum of 5% (up to 7 hours) for administrative tasks
3 hours Hospital orientation and induction on emergency procedures, admin meetings.
As above
√ B/Roberts
1 hour Client education session run by OT on home modifications.
Total hours at this prac site 148 hours 115 hours face to face + 28 hours preparation + 5 hours administration
Please note at least some of the hours of supervision within this category must be supervised by an AEP.
Clinical supervisor: student ratios may be up to 1:5, with the proviso that there must be some 1:1 contact for each placement.
Peter SMITH
I certify that the information supplied is true and correct Signature Date
Title Name
Position and qualifications:I am a current AEP, ESSA ID# __________
Phone Fax
Clinical Cardiac Nurse Coordinator at POW Hospital for 15 years overseeing Stage II & III Cardiac Rehabilitation programs.
(07) 404 1263 (07) 404 1264
B Roberts 01/09/2013
Ms Barbara M. Roberts
Reference for:
Dear Colleague
The above applicant will be applying for accreditation with Exercise & Sports Science Australia (ESSA) as an accredited exercise physiologist (AEP). Requirements of this accreditation include a minimum of 140 hours practicum in the area of musculoskeletal/neurological/
neuromuscular conditions.
Please complete the following form based on your experience with the above applicant:
Patient exposure
Please tick the types of clients the applicant has gained experience with:
Neurological /
Neuromuscular Stroke (CVA) Spinal cord injury (SCI) Acquired brain injury
(ABI) Parkinson’s disease
In the following table, please confirm evidence of the clinical practice the applicant has gained in the relevant area of neuromuscular/neurological/musculoskeletal clients: (expand boxes where necessary)
Breakdown of practicum hours (a minimum total of 140 hours)
Total hours and dates*
Evidence of specific roles and duties completed
Site / location
Competent Not Competent Not able to comment
Name and signature of
referee
Minimum of 60% (at least 84 hours) for face to face exercise program delivery i.e. individualised/group delivery/ instruction of an exercise
program. *Testing/assessments without intent for prescription
cannot be counted
14/09/2013-14/12/2013 16 hours
Assisting AEP in assessing exercise capacity for musculoskeletal and neuro clients.
Exercise for Rehab Clinic
R. Martin
86 hours Prescribing one on one exercise interventions for the range of chronic conditions ticked above.
R. Martin
Maximum of 35% (up to 49 hours) for preparation for face to face delivery, observation and other activities related to the scope of
practice of AEPs
25 hours
Observation of the AEP prescribing services, research on pathologies and designing exercise programs.
Exercise for Rehab Clinic
R. Martin
7 hours Case meeting to discuss client progressions. R. Martin
1 hour
Attended client education session on medication usage. This knowledge was applied to my face to face exercise delivery with clients.
R. Martin
2 hours
Attended staff in service session on clients with multiple co-morbidities and how exercise can be prescribed.
R. Martin
Maximum of 5% (up to 7 hours) for administrative tasks
3 hours Client bookings by phone, filing etc. Staff orientation and induction, admin meetings.
Exercise for Rehab Clinic
R. Martin
1 hour Staff in service for fire safety. R. Martin
1 hour Client education session on nutrition. R. Martin
TOTAL Hours at this site 142 hours 102 hours face to face delivery + 35 hours preparation + 5 hours administration
Please note at least some of the hours of supervision within this category must be supervised by an AEP.
Clinical supervisor: student ratios may be up to 1:5, with the proviso that there must be some 1:1 contact for each placement.
Peter SMITH
I certify that the information supplied is true and correct Signature Date
Title Name
Position and qualifications: I am a current AEP, ESSA ID# _1000__
Phone Fax
Bachelor of Applied Sci (Ex rehab), 5 years as clinical AEP in private practice
(03) 303 1234 (03) 302 1254
R. Martin 14/12/2013
Mr Ron Martin
Reference for:
Dear Colleague
The above applicant will be applying for accreditation with Exercise & Sports Science Australia (ESSA) as an accredited exercise physiologist (AEP). Applicants may choose to participate in 80 hours supervised clinical placement of other health delivery. The activities approved under the 80 other clinical hours may occur in isolation (without a related exercise intervention).
The ‘other’ clinical hours can include:
1. Provision of exercise delivery for pathologies related to cancers, mental health, renal, or other pathologies: the purpose of this is to give students opportunities to strengthen their knowledge and develop competencies in these areas;
2. Diagnostic investigations or procedures (e.g. cardiac, pulmonary or other clinical investigations or procedures);
3. Health checks (e.g. point of care testing);
4. Job capacity assessments, functional capacity assessments;
5. Laboratory/research testing/screening (in isolation);
6. Case management;
7. Health promotion, health education or workplace health programs;
8. Other related activities as described in the AEP generic and target pathology criteria (of the evidence based criteria table).
Please complete the following form based on your experience with the above applicant:
Skills and experience
In the following table, please confirm evidence of the clinical practice the applicant has gained in the relevant area of other health delivery:
(expand boxes where necessary)
*Clinical supervisor: student ratios may be up to 1:5, with the proviso that there must be some 1:1 contact for each placement.
Total hours and
dates* Evidence of specific roles and duties completed Site / location
Competent Not Competent Not able to comment
Name and signature of referee
26/06/2013 to 30/08/2013
14 hours
Delivered 12 education sessions on self-monitoring physical activity for cardiac clients.
2 hours research for development of an educational manual used with clients
15 hours face to face delivery of exercise sessions with breast cancer client in clinic.
5 hours research into cancer treatment & exercise recommendations, designing exercise program, updating SOAP
notes.
Assisting physiotherapist perform FCE’s and ergonomic workstation assessments as part of pre-employment screening
The Wellness
Centre K. Williams
K.Williams TOTAL Hours at
this site 44 hours
*Clinical supervisor: student ratios may be up to 1:5, with the proviso that there must be some 1:1 contact for each placement.
Declaration: (To be completed by each referee listed in the table above)
I certify that the information supplied is true and correct Signature Date
BEx &Sp Sci, Masters Clinical Exercise Physiology, working as an AEP for 3 years in private practice.
(03) 985 6423 (03) 985 6424
Miss Katie Williams