Organizational & Foundational Course Initial Application (REP ORG)

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Important Note:  Before you start this application, please read through the application instructions as there is important information about successful completion. This includes how to properly submit supporting documentation as well as information regarding various course delivery formats. Applications that do not follow the available instructions will be returned for resubmission.

You can also access this application via PDF as well.

Section 1: Organization and Contact Person Information

Organization: School, business, or teaching organization

Director/Owner/Founder: Person who has general and/or overall responsibility for organization

Contact Person: Person within the organization who is completing this application and responsible for ongoing communication with S4OM Education Committee

The Contact Person agrees to:

  • Review Education Standards for S4OM Foundational Courses and ensure course curriculum meets these standards.
  • Be responsible for the review and submission of the entire application following application instructions.
  • Ensure all supporting documents are attached and properly labeled.
  • Ensure each instructor is a current Preferred Practitioner (PP), and their Instructor Application is complete.

    Respond to communications from S4OM about application status.

  • Communicate with S4OM about significant REP Org changes, such as:
    • Instructor additions or deletions
    • Foundational Course title changes
    • REP Organization name changes
    • Significant changes to curriculum, class format or delivery
  • Communicate with S4OM about renewal process.

 

REP Organization Initial Application

Section 1: Organization and Contact Person Information

Organization Address:(Required)

Director/Owner/Founder Name(Required)

Contact Person Name(Required)

Check the box that best describes your program and then go to the appropriate section.

Section 2: School Program

2.1 Program/Course Title and Hours

Note: The title of the program/course must match the title on the certificate of completion/ achievement or diploma/degree
Note: The title of the program/course must match the title on the certificate of completion/ achievement or diploma/degree
Check the boxes associated with the curriculum in this application:
Continuing Education/Advanced Education offered by a massage therapy school

2.2 School Leadership Responsible for Oncology Massage Therapy Curriculum

Oncology Massage Therapy Program Director/Curriculum Coordinator/Director of Education: The person who oversees the oncology massage therapy curriculum.
Clinical Instructor(s): Faculty members providing Clinical Learning Activities (CLA) for a Foundational Course. See Education Standards for more information about CLA. Note: Each instructor must be a Preferred Practitioner (PP) and submit a completed Instructor Application, along with any necessary attachments.

Section 3: Continuing Education (CE) Provider/Independent or Advanced Education Provider

Note: The title of the course must match the title on the certificate of completion/achievement

3.1 Course Title and Hours

3.2 Instructor Information

Note: Each instructor must be a Preferred Practitioner (PP) and submit a completed Instructor Application, along with any necessary attachments.
Instructor Application is required for any person responsible for managing and/or qualified to present the entire course. Instructor Application is not required for: ● Guest or Resident Lecturer: A person who either occasionally or consistently presents on a specific topic in their area of expertise. ● Teaching Assistant: A person who provides support for instructor.

Section 4: Curriculum Overview

4.1 Curriculum Summary

4.2 What specific sources or materials were used in the development of the curriculum content of this course?

4.3 Learning Outcomes

A learning outcome is a written statement that reflects the knowledge or skills that a student will have as a result of participating in the Foundational Course. The outcomes should be able to be objectively assessed and/or measured by instructor or evaluator.

List at least two (2) learning outcomes per curriculum standard in the list below.

Example: Standard C: Clinical Considerations: Massage Therapy Adjustments Related to Disease and Treatment Side Effects Learning outcome: During an oral quiz, therapists will be able to list 5 side effects of chemotherapy. Learning outcome: During Comprehensive Practical, therapists will identify body regions at risk of lymphedema and demonstrate appropriate pressure and direction of strokes. Learning outcome: During a role play exercise, therapists will ask a practice client at least 3 questions to identify the risk or extent of bone metastasis.
List learning outcome 1. and 2.
List learning outcome 1. and 2.
List learning outcome 1. and 2.
List learning outcome 1. and 2.
List learning outcome 1. and 2.

4.4 Clinical Learning Activities (CLA) Assessment Tools

Describe the assessment process for each of the four areas listed below. Attach corresponding support material if desired, such as intake form, worksheets, screen shots, video links. Please note: If your Foundational Course is delivered in multiple formats, it is likely that your assessment tools vary. For each format you list (i.e., in-person, virtual or hybrid) please describe the assessment tools used for the four skill sets below. The box will expand as needed, no additional attachment or application is necessary.
● How do you assess student’s hands on skills as they apply appropriate oncology massage protocols for common client considerations?
● Effective communication with clients: o Describe how students conduct an in-depth interview and assessment of current client health status. o How do you assess student–client communication, i.e., discussing needed adjustments to the treatment plan, answering any client questions, and demonstrating therapeutic presence?
● How is student’s proposed massage treatment plan assessed to ensure that they have thoroughly reviewed health history and designed a safe therapeutic session.
● Describe the model(s) of your Comprehensive Practical, which would include how it is set up and managed, and how each student is assessed.

4.5 Outline of program/course content

Note: If you have virtual components, please note which are synchronous and asynchronous. School Program/Course: Attach an outline or syllabus of the oncology massage course content. CE/Advanced Course: Attach a breakdown by day and hour of the topics covered. Indicate which parts are lecture, demonstration, Clinical Learning Activities, Comprehensive Practical, etc.
Max. file size: 300 MB.
4.6 Course Format
Check the box(es) associated with the format of your course.

Section 5: Related Information

5.1 Organizational approval/accreditation as a massage therapy education provider

(e.g., NCBTMB, FSMTB, COMTA, ACCSC, ABHES, ACCET, COE, or another approval/accreditation organization). Attach documentation showing status. Maximum of three.
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Max. file size: 300 MB.
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Max. file size: 300 MB.
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Max. file size: 300 MB.

5.2 Course Completion

Check the box for the appropriate type of certificate. Attach a blank copy of the corresponding certificate.

Section 6: S4OM REP Organization Code of Conduct Agreement

On behalf of the S4OM Recognized Education Provider Organization, I attest that we will:(Required)
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