Cardiopulmonary/metabolic Practicum Clinical Practicum Supervisor Form
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1
2CLINICAL PRACTICUM SUPERVISOR FORM
CARDIOPULMONARY/METABOLIC PRACTICUM
Supervision for:
Dear Supervisor
The above applicant will be applying for exercise physiology accreditation (AEP) with Exercise & Sports Science Australia (ESSA).
Requirements of this accreditation include a minimum of 140 hours practicum in the area of cardiopulmonary/metabolic conditions.
CLIENT EXPOSURE
Please tick the types of conditions the applicant has gained experience with:
Metabolic
Obesity
Dyslipidaemias
Impaired glucose
Diabetes mellitis
Hypertension
COPD
Myocardial infarction
Cardiopulmonary
Chronic heart failure
Asthma
Peripheral vascular disease
Other
Coronary artery disease
Cystic fibrosis
EXPERIENCE
Please complete the following table.
BREAKDOWN OF PRACTICUM
TOTAL
NAME AND
HOURS
HOURS
EVIDENCE OF SPECIFIC ROLES
SITE /
SIGNATURE OF
(A MINIMUM TOTAL OF 140 HOURS)
AND
AND DUTIES COMPLETED
LOCATION
SUPERVISOR
DATES
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
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 an AEP
Maximum of 5% (up to 7 hours) for
administrative tasks
Total hours at this site
•
Please note at two 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.
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