2021 Clinical Component Examiner Application
Before submitting your application, please ensure that the following are completed:
Application form
Confidentiality Agreement Conflict of Interest Form I confirm:
I am able to work virtually I have access to:
• Stable internet connection (preferably hardwired)
• Computer/Laptop must have camera/webcam and microphone
• Either Microsoft Windows or Apple Mac OS operating system
• Required browsers for Windows and Mac:
• Google Chrome
• Edge – Chromium-based Edge only on Windows 10
• IMPORTANT: Internet Explorer (Windows and Mac) and Safari for Mac are not supported.
We hope to schedule you on alternating weeks within the following windows. Please indicate which day(s) you can commit for full day examination within each window. Please indicate any black-out dates (any dates you CANNOT work) within each window.
OSCE Scheduling Windows Saturday Monday Wednesday Black-out dates
August 28 – October 1, 2021 October 2 – October 29, 2021 October 30 – November 26, 2021 November 27 – December 10, 2021
Additional dates due to holiday weekends: Yes No
Thursday September 9, 2021 Thursday October 14, 2021 Friday October 15, 2021
I understand that, for the purpose of the virtual exam, I will be recorded in my interaction (recorded data will belong to CAPR for the purpose of scoring, review and exam validity purposes).
2021 Clinical Component Examiner Application
Please describe your current practice & years in this area of practice:
Do you have previous experience as a Clinical Examiner? Yes No PERSONAL INFORMATION:
First Name:
Last Name:
Address:
City: Province: Postal Code:
Telephone:
Email:
LANGUAGES SPOKEN FLUENTLY: English French Other (specify)
REGISTRATION AND LICENSE INFORMATION:
Province: License #:
School of Graduation:
Year of Graduation:
Completed PCE: Yes No If Yes, year of completion:
AREA OF PRACTICE: You MUST check () at least one
Neuromusculoskeletal Cardiopulmonary-vascular
Neurological Multisystem
To best match your work experience with the practical exam, please check () all the appropriate areas of practice/expertise:
Administration Student Education Acute Care Rehabilitation Private Practice Community Care
Respiratory Long-Term Care Mixed age groups Geriatrics Pediatrics Other: (please specify)
2021 Clinical Component Examiner Application
I understand that during my association with the Canadian Alliance of Physiotherapy Regulators (CAPR) in any capacity, such as Evaluation Services and CAPR Committees and groups: Examiners, Written/Clinical Test Development Group, Written/Clinical Item Generation Teams, Evaluation Services Committee, Board of Examiners, Appeals Resource Group/Appeal Panels for the Physiotherapy Competency Exam (PCE), development groups, evaluations or other services, I will have access to exam information and/or material and that the copyright of all exam materials belongs exclusively to the CAPR.
I specifically acknowledge that the content of the Written and Clinical Components of the Physiotherapy Competency Examination is highly confidential in nature.
EXAMPLE OF BREACHES IN CONFIDENTIALITY INCLUDE, BUT ARE NOT LIMITED TO:
• Comparing candidate responses with colleagues
• Disseminating exam content during and/or after the exam
• Copying, sharing or removing exam material from the exam site
• Participating in the development, administration and review of preparatory practice exams, cases, educational courses, or other materials or activities which are specifically designed to help candidates prepare for the PCE exam, for example, presenting at information sessions organized by physiotherapy organizations to academic programs offering personal experiences at the clinical exam.
I DECLARE THAT I (PRINT FULL NAME): _
• Will not disseminate or reveal to others exam materials and/or content
• Will not discuss or disclose exam content (including standardized patient portrayals and findings, oral and written questions, station cases etc.) at any time and in any way even after the examinations ends
• Will not participate in presentations or information sessions organized by physiotherapy organizations to academic programs offering personal experiences at the clinical exam.
• Shall ensure that confidential information is not inappropriately accessed, used, or released either directly by me, or by virtue of my signature or security access to premises or systems
• Will ensure, to the best of my abilities, the confidentiality and security of all information and materials of the CAPR
• Will not disclose to another person my username and password for accessing electronic information, the premises, or system
• Will continue to be bound by the obligations of the confidentiality agreement even after my contract, exam or other work with CAPR is over.
NOTE: By signing this confidentiality agreement you agree to abide by this agreement and what you entered into. Breaching this confidentiality agreement may result in immediate termination at the absolute discretion of the CAPR. Any breach or disclosure to any persons may be subject to liquidation damages to the amount of $10,000 per disclosure and any other damages or legal relief or remedy that CAPR may be entitled to at law, including without limitation further damages an injunction or specific performance. Notwithstanding the above, CAPR also reserves to right to report any breach of confidentiality to the appropriate regulatory college.
SIGNATURE DATE
CONFIDENTIALITY AGREEMENT
2021 Clinical Component Examiner Application
This Conflict of Interest Declaration Form is intended to facilitate communication between CAPR and all parties involved with CAPR activities. Examples include specific services in Evaluation Services and CAPR Committees and groups: Examiners, Written/Clinical Test Development Group, Written/Clinical Item Generation Teams, Evaluation Services Committee, Board of Examiners, Appeals Resource Group/Appeal Panels. Declarations submitted to CAPR are assessed to determine whether the reported situation constitutes an actual, potential, or perceived conflict between your personal or professional interests and your official duties on behalf of CAPR. If such a conflict is found to exist, a plan will be developed to resolve the situation.
UNDERSTANDING
Actual – Describes a situation in which a person has knowledge of individual(s) or organisations interest that is sufficient to influence the exercise of their duties and responsibilities.
Potential – Incorporates a concept of foreseeability: when individuals can foresee that a private interest may someday be sufficient to influence the exercise of their duty but has not yet.
Perceived – When there is reasonable apprehension, which a reasonably well-informed person could properly have, that a conflict of interest exists; whether this is the case or not.
Note: Examiners cannot be engaged in the following CAPR activities: Board of Examiners, Appeals Resource Group and Appeal Panels.
TO BE COMPLETED ANNUALLY BY ALL PARTIES WORKING/VOLUNTEERING WITH CAPR
I understand and declare any conflicts below while working/volunteering with CAPR and acknowledge that any actual, potential or perceived conflict between my role and responsibility to that of CAPR will be managed by my commitment to work in the best interest of the CAPR and in the interest of public protection.
I have no further conflict of interests to declare at this time.
I have a conflict of interest (actual, potential or perceived) to declare involving:
Employment Academic activity Professional activity
Physiotherapy student mentorship/relationship Political activity
Personal Relationship
Academic appointment: please specify:
Student education activities and your related role: please specify:
Other:
CONFLICT OF INTEREST DECLARATION FORM
2021 Clinical Component Examiner Application
PLEASE PROVIDE THE NAME(S) OF THE INDIVIDUAL(S) WHO MAY BE TAKING THE EXAM IN 2021
SIGNATURE DATE
PRINT NAME
DESCRIPTION OF CONFLICT:
2021 Clinical Component Examiner Application
1. In consideration of the payments made to me by the Canadian Alliance of Physiotherapy Regulators (“CAPR”) the undersigned hereby releases CAPR, and all its affiliates, subsidiaries, directors, officers, partners, employees, trustees, shareholders, insurers and agents (hereinafter collectively referred to as the "Company"), jointly and severally from any and all actions, causes of action, contracts, obligations, liabilities, claims, complaints, and demands of every nature or kind which the undersigned ever had, now has, or hereafter may have in respect of any cause, matter, or thing, and without limiting the generality of the foregoing, in respect of any and all claims in contract or in tort or statutory rights or remedies arising out of or in any way connected with the engagement of the undersigned as an independent contractor, dependent contractor, or employee of the Company or the cessation of that engagement, including any and all claims for damages, fees, salary, wages, commissions, vacation pay, termination pay, severance pay, compensation in lieu of notice, overtime payments, expense reimbursement, short term or long term disability and other insurance benefits or benefit coverage, bonus (individual or group), incentive payments, allowances, and retirement or pension allowances. The scope of this Release extends to any and all acts of harassment, sexual harassment, bullying, threats, or intimidation, actual or alleged, by the Company, whether at the workplace or elsewhere, and whether carried out during working hours or at other times.
2. NO ADMISSION
The payment given to the undersigned pursuant to the above paragraph does not constitute any admission of liability by or on behalf of the Company.
3. EMPLOYMENT STANDARDS
The undersigned acknowledges and agrees the undersigned was not entitled to any wages, pay, commissions, overtime pay, vacation pay, general holiday pay, bonuses, and termination pay pursuant to the applicable employment standards legislation in the Province or Territory in which the exam centre operates (“Employment Standards Legislation”). For the above consideration, the undersigned agrees and undertakes that it will not file any claim against the Company pursuant to the Employment Standards Legislation, and releases the Company of any liability for any past violations of the Employment Standards Legislation. If the undersigned hereafter makes any such claim or commences or threatens to commence an action against the Company, this Release may be raised as an estoppel and complete bar to that claim or action.
4. BENEFITS AND INSURANCE CLAIMS
The undersigned acknowledges and agrees that as their relationship with the Company was an independent contractor relationship, they were not at any time entitled to any employment benefits.
5. INDEMNITY FOR TAXES, ETC.
The undersigned hereby agrees to hold harmless and indemnify the Company from and against all claims, assessment, taxes, interest, premiums, penalties, or demands that may be made by the Canada Revenue Agency, the Employment Insurance Commission, the Canada Pension Plan Commission, or other government official, requiring the Company to pay any amounts, including income tax, charges, interest, penalties, or other assessments under the Canada Income Tax Act, the applicable Provincial or Territorial Income Tax Act , the Employment Insurance Act, and the Canada Pension Plan, or under any other enactment having jurisdiction over the Exam Centre. If any such amounts, including income tax, charges, interest, penalties, or other assessments, are demanded, the undersigned will repay the Company forthwith on demand, in the amount demanded.
6. UNDERSTANDING
The undersigned has read and understood the terms of this Release, and voluntarily agrees to be bound by them, without duress and after having been provided the opportunity to obtain independent legal advice. The undersigned
INDEPENDENT CONTRACTOR RELEASE
2021 Clinical Component Examiner Application
IN WITNESS WHEREOF I have executed this Release this ___ day of ______________ 2021.
Witness' signature ) )
) ) _______________________________________
(printed name) ) (printed name)
Applicant' signature
