NAIOMT/Messiah University Orthopedic Residency Program Application Survey

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* 1. Residency Applicant Information

Name (please include credentials, ie. PT, DPT, ATC, etc.)

Company

Home Address

Home Address 2

City/Town

State/Prov

ZIP/Postal Code

Country

Email Address (personal not work email)

Phone Number

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* 2. List your credentials (ie. PT, DPT, etc)

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* 3. Enter Birth Date

Date

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* 4. CLICK HERE to read the Residency Program admission requirements.

I acknowledge I have read the Residency Program admission requirements.

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* 5. How did you hear about us?

NAIOMT course

Messiah University

Conference - CSM

Conference - AAOMPT

Conference - Orthopedic Section

Colleague

APTA Search

Internet/social media

Employer

Other (please specify)

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* 6. What PT school did you graduate from?

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* 7. Please provide a one paragraph biography below (name, credentials, PT school, date of graduation, current pending employment name and location and other professional information.

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* 8. Graduation date

Date / Time

Date

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* 9. Highest degree awarded

MSPT

BSPT

DPT

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* 10. Are you an APTA member in good standing? Note: You must be a current APTA member in good standing prior to, and for the duration of the residency training.

Yes

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* 11. What is your APTA membership number?

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* 12. Are you a member of AAOMPT?

Yes

If you answered "yes" to this question, please provide your membership number.

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* 13. Do you currently have, or have ever had, an ABPTS Certification?

Yes

If you answered "yes" to this question, what ABPTS do you, or did you, hold?

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* 14. Do you have other certifications or training (check all that apply)

Dry Needling

Instrument-assisted certification

CSCS

CMPT

COMT

PhD

DsC/ScD or EdD

ATC

CFMT

CHT

MTC

None of the above

Other (please specify)

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* 15. Have you taken any NAIOMT courses? Note: COMT 1-5 courses must be re-taken during ACTIVE enrollment in the NAIOMT/Messiah University Orthopedic Residency Program.

Yes

If you answered "yes" to this question, what NAIOMT courses have you previously taken?

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* 16. PT Licensure State

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* 17. PT License #

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* 18. PT License Expiration Date

Date

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* 19. Please provide the name, email address and phone number of 3 references. [first name, last name/phone number/email address]

Reference #1

Reference #2

Reference #3

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* 20. Do you have a conviction record or pending charges?

Yes

If you answered "yes", please provide details below.

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* 21. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction?

Yes

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* 22. Have you ever had any license, certificate, registration, or other privilege to practice a health care profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority?

Yes

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* 23. Have you ever surrendered a credential in connection with, or to avoid, action by a state, federal, or foreign authority?

Yes

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* 24. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)?

Yes

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* 25. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of a health care profession?

Yes

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* 26. If you answered “yes” to any of the questions (17-22), the comments box below provides an option to explain the circumstances.

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* 27. Current Employer Name

Advanced Kinetics Physical Therapy and Sports Performance

Marathon Physical Therapy and Sports Performance

PRN Physical Therapy

Phoenix Physical Therapy

Other (please specify)

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* 28. Employer Information

Name of Supervisor *

Company *

Address *

Address 2

City/Town *

State/Prov *

ZIP/Postal Code *

Country *

Employer/Supervisor's Email Address *

Employer/Supervisor's Phone Number *

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* 29. Have you negotiated participation in the NAIOMT/Messiah University Orthopedic Residency Program with your employer? *NOTE – Participants in this residency must be employed by one of our clinical practice partners at an ABPTRFE-approved site.

Yes

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* 30. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? “Currently” means within the past two years. “Chemical substances” include alcohol, drugs, and/or medications whether taken legally or illegally

Yes

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* 31. Are you currently engaged in the illegal use controlled substance(s)?“Currently” means within the past two years. Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine) not obtained legally or according to the directions of a licensed health care practitioner.

Yes

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* 32. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety?

Yes

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* 33. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism, or frotteurism?

Yes

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* 34. Upload your CV

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 35. Upload a one paragraph biography. Include your school and professional history and what you like to do in your time outside of work.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 36. Upload a head and shoulder photo in JPG format.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 37. I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me for the residency program.

Yes

NAIOMT/Messiah University Orthopedic Residency Program Application

Question Title

* 1. Residency Applicant Information

Question Title

* 2. List your credentials (ie. PT, DPT, etc)

Question Title

* 3. Enter Birth Date

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* 4. CLICK HERE to read the Residency Program admission requirements.

Question Title

* 5. How did you hear about us?

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* 6. What PT school did you graduate from?

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* 7. Please provide a one paragraph biography below (name, credentials, PT school, date of graduation, current pending employment name and location and other professional information.

Question Title

* 8. Graduation date

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* 9. Highest degree awarded

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* 10. Are you an APTA member in good standing? Note: You must be a current APTA member in good standing prior to, and for the duration of the residency training.

Question Title

* 11. What is your APTA membership number?

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* 12. Are you a member of AAOMPT?

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* 13. Do you currently have, or have ever had, an ABPTS Certification?

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* 14. Do you have other certifications or training (check all that apply)

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* 15. Have you taken any NAIOMT courses? Note: COMT 1-5 courses must be re-taken during ACTIVE enrollment in the NAIOMT/Messiah University Orthopedic Residency Program.

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* 16. PT Licensure State

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* 17. PT License #

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* 18. PT License Expiration Date

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* 19. Please provide the name, email address and phone number of 3 references. [first name, last name/phone number/email address]

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* 20. Do you have a conviction record or pending charges?

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* 21. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction?

Question Title

* 22. Have you ever had any license, certificate, registration, or other privilege to practice a health care profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority?

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* 23. Have you ever surrendered a credential in connection with, or to avoid, action by a state, federal, or foreign authority?

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* 24. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)?

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* 25. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of a health care profession?

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* 26. If you answered “yes” to any of the questions (17-22), the comments box below provides an option to explain the circumstances.

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* 27. Current Employer Name

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* 28. Employer Information

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* 29. Have you negotiated participation in the NAIOMT/Messiah University Orthopedic Residency Program with your employer? *NOTE – Participants in this residency must be employed by one of our clinical practice partners at an ABPTRFE-approved site.

Question Title

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* 32. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety?

Question Title

* 33. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism, or frotteurism?

Question Title

* 34. Upload your CV

Question Title

* 35. Upload a one paragraph biography. Include your school and professional history and what you like to do in your time outside of work.

Question Title

* 36. Upload a head and shoulder photo in JPG format.

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* 37. I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me for the residency program.

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* 38. Please enter date