certification examination for orthopedic physician assistants

PROFESSIONAL TESTING CORPORATION1350 BROADWAY 17th FLOOR

NEW YORK, NY 10018(212) 356-0660

WWW.PTCNY.COM

CERTIFICATIONEXAMINATION

FORORTHOPEDICPHYSICIAN

ASSISTANTSHandbook for Candidates

SUMMER 2009 TESTING PERIODApplication Deadline: June 30, 2009

Testing Begins: Saturday, August 8, 2009Testing Ends: Saturday, August 22, 2009

WINTER 2010 TESTING PERIODApplication Deadline: December 31, 2009Testing Begins: Saturday, February 6, 2010

Testing Ends: Saturday, February 20, 2010

SUMMER 2010 TESTING PERIODApplication Deadline: June 30, 2010

Testing Begins: Saturday, August 7, 2010Testing Ends: Saturday, August 21, 2010

1

PURPOSE OF CERTIFICATION

The National Board for Certification of OrthopedicPhysician Assistants (NBCOPA) endorses the conceptof voluntary, periodic certification by examination forphysician assistants working primarily in orthopedics.The certification process is designed to promoteexcellence in the practice of orthopedic physicianassistants by:

1. Recognizing formally those individuals who meetall the requirements of the NBCOPA.

2. Encouraging professional growth of the physicianassistant in orthopedics.

3. Establishing and measuring the level of knowledgerequired for a certified orthopedic physicianassistant.

4. Providing a standard of requisite knowledgerequired for certification; thereby assisting theemployer, public, and members of the healthprofessions in the assessment of orthopedicphysician assistants.

ELIGIBILITY REQUIREMENTS

Although not a requirement, it is highly recommendedthat candidates have at least two years of college workin the sciences before sitting for the CertificationExamination for Orthopedic Physician Assistants.

1. a. Completion of an orthopedic physicianassistant program, a primary care physicianassistant program, or a nurse practitionerprogram,

ORb. Completion of a related allied health care

program AND at least FIVE years ofexperience in orthopedic work withresponsibility in surgical assisting, history andphysical assessment, and immobilizationtechniques, under the supervision of a Board-certified orthopedic surgeon.

NOTE: A supervising Board-certified orthopedicsurgeon must verify this eligibility and sign theSupervising Physician’s Statement on the candidate'sApplication.

2. Completion and filing of Application and requiredfee for the Certification Examination for OrthopedicPhysician Assistants.

2

3. Agreement to adhere to the following NBCOPACode of Ethics:

a. Pledge to render service to humanity with fullregard to patient.

b. Pledge to safeguard all confidential informationregarding a patient and NBCOPA unlessrequired to divulge such information by law.

c. Pledge to uphold the principles and policies ofNBCOPA.

d. Pledge to strive continually to gain professionalknowledge and experience so as to providebetter health care to patients, physicians, andcommunity served.

SPONSORSHIP AND ADMINISTRATION

The Certification Program for Orthopedic PhysicianAssistants is sponsored solely by the National Boardfor Certification of Orthopedic Physician Assistants.There are six regular members of the board from theAmerican Society of Orthopedic Physician Assistantsplus advisory members including physicians andeducators. The Certification Examination forOrthopedic Physician Assistants is administered forNBCOPA by the Professional Testing Corporation,1350 Broadway - 17th Floor, New York, New York10018, (212) 356-0660, www.ptcny.com.

ATTAINMENT AND DURATION OFCERTIFICATION

Candidates who pass the Certification Examination forOrthopedic Physician Assistants may use OPA-C aftertheir name and will receive certificates from NBCOPA.

Certification as an Orthopedic Physician Assistant isrecognized for a period of four years at which time thecandidate must either retake and pass the CertificationExamination for Orthopedic Physician Assistants ormeet continuing education requirements in effect atthat time in order to retain certification.

DISCLAIMER

State Statutes provide the basic guidelines thatrecognize Allied Health Professionals in theirrespective states. Medical Institutions credentialingcommittees intercept these statutes. These committeesbased on their interpretations decide what privileges togrant individuals applying for employment in theirrespective Institutions. The NBCOPA exam is aNational Certifying Exam. It is your responsibility as apassing candidate of this exam to insure you meet therequirements of your respective State and InstitutionalCredentialing Committee when applying for medicalprivileges within your place of employment.

3

REVOCATION OF CERTIFICATION

Certification will be revoked for either of the followingreasons:

1. Falsification of Application.2. Misrepresentation of certification status.

CONFIDENTIALITY

1. The National Board for Certification of OrthopedicPhysician Assistants will release the individual testscores only to the individual candidate.

2. Individual scores will NOT be sent to employers,educational institutions, school/programs, etc.under any circumstances.

3. Any questions concerning test results should bereferred to NBCOPA.

APPLICATION PROCEDURE

To obtain additional Handbooks for Candidates andApplications, contact Professional Testing Corporation,1350 Broadway - 17th Floor, New York, New York10018, (212) 356-0660, or download fromwww.ptcny.com.

COMPLETION OF APPLICATION

Complete or fill in as appropriate ALL informationrequested on the Application. Mark only one responseunless otherwise indicated.

CANDIDATE INFORMATION: Starting at the top ofthe Application, print your name, address, phonenumbers and e-mail address in the appropriate row ofempty boxes.

ELIGIBILITY AND BACKGROUNDINFORMATION: All questions must be answered.Mark only one response unless otherwise indicated. Ifapplying via Eligibility Route 1a (school/program), usethe following codes on the application:

103 – Orthopedic Physician Assistants Programs200 – Primary Care Physician Assistants Programs300 – Surgical Assistants Programs400 – Athletic Trainers Programs450 – Nurse Practitioner Programs

OPTIONAL INFORMATION: These questions areoptional. The information requested is to assist incomplying with equal opportunity guidelines and willbe used only in statistical summaries. Suchinformation will in no way affect your test results.

4

CANDIDATE SIGNATURE: When you havecompleted all required information, sign and date theApplication in the space provided.

SUPERVISING BOARD CERTIFIED ORTHOPEDICPHYSICIAN’S STATEMENT: Your supervisingboard certified orthopedic physician must verify youreligibility and experience and complete and sign thesupervising physician’s statement. No candidate willbe accepted for the examination without a completedand signed Supervising Physician’s Statement. Besure the signature, title, license number, address, andtelephone number of your supervisor are included.

Mail the Application with the appropriate fee (see FEESbelow) in time to be received by the applicationdeadline to:

NBCOPA ExaminationProfessional Testing Corporation

1350 Broadway – 17th FloorNew York, New York 10018

FEES

Application Fee for Certification Examination forOrthopedic Physician Assistants:

Initial Certification Fee for ASOPA Members..... $400.00Initial Certification Fee for Non-ASOPAMembers................................................................... $475.00Recertification Fee (OPA-Cs only) ........................ $350.00

NOTE: All candidates must pay the Application Fee forinitial certification or recertification (OPA-Cs only).

Make check or money order payable to:NBCOPA EXAMINATION

Visa, MasterCard, and American Express are alsoaccepted. Please complete and sign the credit cardpayment form on the application.

REFUNDS

There will be no refund of fees. Fees will not betransferred from one testing period to another.

voquendo

Text Box

5

EXAMINATION ADMINISTRATION

The Certification Examination for OrthopedicPhysician Assistants is administered during anestablished two-week testing period, at computer-based testing facilities managed by PSI/LaserGradeComputer Testing, Inc. PSI/LaserGrade has severalhundred testing sites in the United States as well asCanada. Please note: Hours and days of availabilityvary at different centers. Scheduling is done on a first-come, first-serve basis. To find a testing center near youvisit: www.lasergrade.com or call LaserGrade at (800)211-2754. You will not be able to schedule yourexamination appointment until you have received anEligibility Notice from PTC.

ONLINE TUTORIAL AND SAMPLE TEST

A Tutorial and a Sample Demonstration Test can beviewed online.

Browse to www.lasergrade.com Select Test Taker/Candidates menu Select Testing Software Demo Select the "General Education Demo Test" Click on the "Start LaserGrade Online Demo

Test" button.

This online Tutorial and Sample Test can give you anidea about the features of the testing software.

SCHEDULING YOUR EXAMINATIONAPPOINTMENT

Once your application has been received andprocessed, and your eligibility verified, you will bemailed an Eligibility Notice within 6 weeks prior to thestart of the testing period. The Eligibility Notice pluscurrent government issued photo identification mustbe presented in order to gain admission to the testingcenter. A candidate not receiving an Eligibility Noticeor other correspondence at least three weeks before thebeginning of the testing period should contact theProfessional Testing Corporation by telephone at (212)356-0660.

The Eligibility Notice will indicate where to call toschedule your examination appointment as well as thedates in which testing is available. Appointment timesare first-come, first-serve, so schedule yourappointment as soon as you receive your EligibilityNotice in order to maximize your chance of testing atyour preferred location and on your preferred date.

6

SPECIAL NEEDS

Special testing arrangements will be made forindividuals with special needs. Submit theApplication, Examination Fee, and a completed andsigned Request for Special Accommodations Form,available from www.ptcny.com or by calling PTC at(212) 356-0660. Requests for testing accommodationsfor individuals with special needs must be received atleast EIGHT weeks before the testing period starts.

CHANGING YOUR EXAMINATION APPOINTMENT

If you need to cancel your examination appointment orreschedule to a different date within the two-weektesting period, you must contact PSI/LaserGrade at(800) 211-2754 no later than noon, Eastern StandardTime, of the second business day PRIOR to yourscheduled appointment.

RULES FOR THE EXAMINATION

1. No books, papers, calculators, or other referencematerials may be taken into the examination room.

2. No signaling devices, including cellular phones,pagers, and alarms, may be operative during theexamination.

3. No test materials, documents, or memoranda of anysort are to be taken from the examination room.

4. The examination will be held ONLY on the day andthe time scheduled.

5. No questions concerning content of the examinationmay be asked during the testing period. Thecandidate should carefully read the directions thatare provided on screen at the beginning of theexamination session.

REPORT OF RESULTS

Candidates will be notified in writing by PTC withinfour weeks of the close of the testing period whetherthey have passed or failed the examination. Scores onthe major areas of the examination and on the totalexamination will be reported.

7

REEXAMINATION

The Certification Examination for OrthopedicPhysician Assistants may be taken as often as desired,upon filing of a new Application and fee. There is nolimit to the number of times the examination may berepeated.

CONTENT OF THE EXAMINATION

The Certification Examination for OrthopedicPhysician Assistants is composed of a maximum of 250multiple-choice, objective test questions with a totaltesting time of four hours.

The questions for the examination are developed byindividuals with expertise in orthopedics and arereviewed for construction, accuracy, andappropriateness by representatives of NBCOPA. TheNBCOPA, with the advice and assistance of theProfessional Testing Corporation, prepares theexamination.

The Certification Examination for OrthopedicPhysician Assistants will be weighted in approximatelythe following manner:

I. Anatomy and Physiology ....................................15%II. Musculoskeletal Conditions ................................30%III. Orthopedic History and Physical Examination 10%IV. Imaging and Laboratory Studies ........................10%V. Treatment of Musculoskeletal Conditions ........35%

8

CONTENT OUTLINE

I. ANATOMY AND PHYSIOLOGYA. Skeletal

1. Bonesa. Structure

1. Composition2. Special Anatomic Configurationsa. Fossab. Foramenc. Condyled. Trochantere. Crestf. Spinous Processg. Tuberosityh. Other3. Growth4. Coverings5. Blood Supply

b. Types1. Long Bones2. Short Bones3. Flat Bones4. Irregular Shaped Bones

c. Functions1. Support2. Protection

2. Jointsa. Structure

1. Cartilagea. Articularb. Meniscalc. Other

2. Ligaments3. Synovia4. Joint Fluid

b. Types1. Ball and Socket2. Hinge3. Gliding4. Other

c. Functions1. Flexion and Extension2. Abduction and Adduction3. Rotation and Circumduction4. Supination and Pronation5. Inversion and Eversion6. Other

B. Neuromuscular1. Muscles

a. Structure1. Belly2. Tendons3. Origins and Insertions

9

b. Typesc. Locationd. Actions

2. Nervesa. Structure

1. Central2. Peripheral

b. Locationc. Function

II. MUSCULOSKELETAL CONDITIONSA. Trauma

1. Fractures and Dislocationsa. Openb. Closed

2. Soft Tissue Injuries3. Complications

B. Disorders1. Upper Extremities2. Lower Extremities3. Spine

a. Cervicalb. Thoracicc. Lumbard. Sacrum and Coccyx

C. Diseases1. Neuromuscular2. Skeletal3. Deficiency4. Blood Dycrasias5. Systemic

D. Joint Conditions1. Arthritic

a. Degenerativeb. Inflammatoryc. Posttraumatic

2. Soft Tissuea. Inflammatoryb. Attritional

3. CongenitalE. Infections

1. Acute2. Chronic3. Periprosthetic

F. Neoplasms1. Malignant2. Benign

G. Muscle, Ligament, Tendon, and CartilageConditions

III. ORTHOPEDIC HISTORY AND PHYSICALEXAMINATIONA. Present Illness

1. Symptoms2. Cause3. Duration

10

4. Prior Treatment5. Changes Since Onset6. Present Medical Status

B. Patient History1. Serious Illness2. Surgery3. Hospitalizations4. Similar Conditions or Broken Bones5. Congenital Problems6. Present Medications7. Activities of Daily Living8. Alignment

C. Family HistoryD. Physical Examination

1. Observationa. Gaitb. Swellingc. Deformities and Scarringd. Stature and Posturee. Nutritional Statusf. Muscular Developmentg. Amputationsh. Other

2. Manual Examinationa. Palpationb. Range of Motionc. Stabilityd. Strengthe. Neurologicalf. Circulation

IV. IMAGING AND LABORATORY STUDIESA. Imaging

1. Roentgenographya. Routineb. Tomographyc. Computerized Axial Tomography

2. Magnetic Resonance Imaging3. Nuclear Studies4. Ultrasonography5. Special Diagnostic Procedures

a. Arthrographyb. Fluoroscopyc. Venographyd. Other

6. FindingsB. Laboratory Studies

1. Urine2. Blood3. Synovial Fluid4. Cultures

C. Other Diagnostic Procedures

11

V. TREATMENT OF MUSCULOSKELETALCONDITIONSA. Nonsurgical

1. Castinga. Indicationsb. Types

1. Plaster2. Fiberglass and Other Synthetics

c. Anatomical Site1. Upper Extremity2. Lower Extremity3. Body

d. Application and Procedures1. Preparation2. Padding3. Special Considerations4. Removal

e. Duration of Treatmentsf. Complications

2. Supportive and Assistive Devicesa. Taping, Strapping, Bandagesb. Splints and Braces

1. Static2. Dynamic3. Prefabricated4. Custom

c. Ambulatory, Assistive Devices(Crutches, Walkers, Canes)

3. Traction4. Physical Therapy and Exercise/

Continuous Passive Motion5. Complications6. Other

B. Pharmacologic1. Types, Functions, and Side Effects

a. Analgesicsb. Muscle Relaxantsc. Antibioticsd. Steroidse. Anticoagulantsf. Anti-inflammatoriesg. Vasoconstrictorsh. Antiemetics

2. Administrationa. Oralb. Parenteral

1. Intravenous Including PatientControlled Analgesia

2. Intramuscular3. Subcutaneous4. Regional

c. Other3. Interactions

12

a. Other Drugsb. Disease Conditions

C. Surgical1. Indications2. Preoperative Planning and Care3. Types of Procedures

a. Reduction1. Fractures2. Dislocations

b. Reconstruction1. Arthroplasty

a. Replacementb. Interpositional

2. Ligaments3. Digits4. Fusion

c. Repair1. General2. Reimplantation

d. Removal1. Amputation2. Foreign bodies3. Other

e. Wound care1. Traumatic2. Elective

f. Diagnosis1. Arthroscopy2. Other

4. Intraoperative Managementa. Positioningb. Anesthesiac. Incisiond. Equipment

1. Instrumentation2. Implants3. Sutures4. Other

e. Sterilization Procedures5. Postoperative Management

a. Immediateb. Hospitalc. Long Term

6. ComplicationsD. Patient EducationE. DocumentationF. Infection ControlG. Safety

13

SAMPLE QUESTIONS

1. The triceps reflex is controlled by what nerve root?

1. C52. C63. C74. T1

2. What type of joint is the hip joint?

1. Hinge2. Pivot3. Condyloid4. Ball and socket

3. Which of the following fractures is LEAST likely tobe initially demonstrated on an X ray?

1. Cuboid2. Boxer's3. Scaphoid4. Bennett

4. The skeleton of the adult hand consists of howmany bones?

1. 82. 103. 194. 27

5. Osteoblasts are responsible for bone

1. growth.2. nutrition.3. formation.4. destruction.

6. Which of the following arteries would most likelybe injured in a supracondylar fracture of the elbow?

1. Radial2. Axillary3. Brachial4. Subscapular

14

7. What is the best method of treatment for a 13-year-old who presents with a slipped capital epiphysis?

1. Braces2. Surgery3. Traction4. Crutches with partial weight bearing

8. A deficiency of vitamin D may cause which of thefollowing bone problems?

1. Rickets2. Pellagra3. Dwarfism4. Osteoporosis

9. Which of the following would be an immediatetreatment for pulmonary emboli?

1. Intravenous heparin2. Intramuscular heparin3. Oral warfarin (Coumadin)4. Subcutaneous adrenalin (Epinephrine)

10.What is the main extensor muscle of the hip?

1. Semitendinosus2. Gluteus medius3. Gluteus maximus4. Gluteus minimus

Answers to sample questions1.3, 2.4, 3.3, 4.3, 5.3, 6.3, 7.2, 8.1, 9.1, 10.3

15

REFERENCES

The following references may be of some help inpreparing for the examination. The list does notattempt to include all acceptable references nor is itsuggested that the examination questions arenecessarily based on these references.

Bellabarba C, Berger RA, Bentley CD, Quigley LR, JacobsJJ, Rosenbrg AG, Sheinkop MB, Galante JO: Cementlessacetabular reconstruction after acetabular fracture. J BoneJoint Surg 83A(6):868-876, 2001.

Berry DJ, Harmsen WS, Cabanela ME, Morrey BF: 25Year Survivorship of 2000 Consecutive PrimaryCharnley Total Hip Arthroplasties: Factors GoverningAcetabular and Femoral Component Survivorship. JBone Joint Surg(A) Feb., 2002.

Blasser KE: Intertrochanteric fracture. In:Reconstructive Surgery of the Joints, ChurchillLivingstone, Philadelphia, PA, B. F. Morrey (ed), pp1062-1076, 1996.

Feugier P, Fessy MH, Carret JP, Fischer LP, Bejui J,Chevalier JM: Total hip arthroplasty. Risk factors andprevention of iatrogenic vascular complications.Annales de Chirurgie 53(2):127-135, 1999.

Gill DRJ, Morrey BF: The Coonrad-Morrey total elbowarthroplasty in patients who have rheumatoid arthritis.A ten to fifteen year follow-up study. J Bone Joint Surg80A(9):1327-1335, 1998.

Haidukewych, G.J.; Israel, T.A.; and Berry, D.J.:Reverse obliquity of fractures of the intertrochantericregion of the femur. J. Bone Joint Surg. 83A(5):643-650,May 2001

Kenzora JE et al: Outcome after hemiarthroplasty forfemoral neck fractures in the elderly. Clin Orthop 1998Mar;(348):51-8

Klapach AS, Callaghan JJ, Goetz DD, Olejniczak JP,Johnston RC: Charnley total hip arthroplasty with useof improved cementing techniques. J Bone Joint Surg83A(12):1840-1848, 2001.

Madan S, Jowett RL, Goodwin MI: Recurrentintrapelvic cyst complicating metal-on-metal cementedtotal hip arthroplasty. Archives of Orthopaedic &Trauma Surgery 120(9):508-510, 2000

16

Mears D, Velyvis J: Acute total hip arthroplasty forselected displaced acetabular fractures. J Bone JointSurg 84A:1, 2002.

Morrey, BF: Master Technique in Orthopaedic Surgery:The Elbow. 2nd Edition. Lippincott, 2002.

Morrey, BF: The Elbow and Its Disorders. 3rd Edition.W. B. Saunders, 2000.

Ramsey ML, Adams RA, Morrey BF: Instability of theelbow treated with semiconstrained total elbowarthroplasty. J Bone Joint Surg 81A:38-47, 1999.

Rispoli M, Damion: Tarascon Pocket Orthopaedica, 2nd

edition Tarascon Publishing 2005

Joaquin Sanchez-Sotelo; Berry, D.J.; W. Scott Harmsen:Long-Term Results of a Collared Matte-FinishedFemoral Component Fixed with Modern CementingTechniques. A Fifteen-Year-Median Follow-up Study JBone Joint Surgery(A) Jan., 2002.

Schneeberger AG, Adams R, Morrey BF:Semiconstrained total elbow replacement for thetreatment of posttraumatic arthritis and dysfunction. JBone Joint Surg 79A:1211-1222, 1997.

Sethuraman V, Hozack WJ, Sharkey PF, Rothman RH:Pseudoaneurysm of femoral artery after revision totalhip arthroplasty with a constrained cup. J Arthroplasty15(4):531-534, 2000.

Sperling JW, Kozak TK, Hanssen AD, Cofield RH.Infection after shoulder arthroplasty. [In ProcessCitation]. Clin Orthop. 2001:206-16.

Sperling JW, Cofield RH. Revision total shoulderarthroplasty for the treatment of glenoid arthrosis [seecomments]. J Bone Joint Surg Am. 1998;80:860-7.

Wirth MA, Rockwood CA, Jr. Complications of totalshoulder-replacement arthroplasty. J Bone Joint SurgAm. 1996;78:603-16.

PTC09046

NBCOPA, PROFESSIONAL TESTING CORPORATION, 1350 BROADWAY, 17th FLOOR, NEW YORK, NY 10018WWW.PTCNY.COM (212) 356-0660 ALL RIGHTS RESERVED PTC09042

Application for

Certification Examination forOrthopedic Physician Assistants

MARKING INSTRUCTIONS: This form will be scanned by computer,so please make your marks heavy and dark, filling the circlescompletely. Please print uppercase letters and avoid contact withthe edge of the box. See example provided.


Last Name & Suffix, if any

Number and Street Apartment Number

City State/Province Zip/Postal Code

Daytime Phone

- -

(Continue on page 2)

C.

Darken only one choice for each question unless otherwise directed.

Candidate Information

Application for

Evening Phone

- -

B.

Page 1

Email Address

E.

D.

PERCENT OF WORKING TIME CURRENTLY SPENT INORTHOPEDICS:

Less than 25%

25 to 50%

51 to 75%

More than 75%

HIGHEST HEALTH CREDENTIAL HELD:LPN/LVNRN

NPPA

PA-COT-C

CSTATC

PTOther

HIGHEST ACADEMIC LEVEL ATTAINED:High School Diploma or EquivalencyAssociate DegreeBachelor's Degree

Master's DegreeDoctoral Degree

PRIMARY PLACE OF EMPLOYMENT:(Darken only one response.)

Physician's office

General or community hospital

Military facility

Orthopedic clinic (other than above)

Other


A. ELIGIBILITY ROUTE: Select the ONE route whichdetermines your eligibility to take the examination:

School/Program (provide information below)

Other allied health program plus five years experience

School Name:

City/State:

Year Completed:

School Code:(See Handbook.)

F. EXPERIENCE IN THE CARE OF ORTHOPEDICPATIENTS:

Under 1 year

1 to 3 years

4 to 5 years

6 to 10 years

More than 10 years

G. ARE YOU A MEMBER OF ASOPA?

No YesNote: Membership in ASOPA is not required.

Eligibility and Background Information

ARE YOU A MEMBER OF AAPA (AMERICANACADEMY OF PHYSICIANS' ASSISTANTS)?

No Yes

H.

Winter SummerExamination Date

First Name Middle Initial

57665


Application for


Page 2

Age Range:

Under 2525 to 2930 to 39

40 to 4950 to 5960+

Note: Information related to race, age, and gender is optional and is requested only to assist in complying with general guidelines pertaining to equalopportunity. Such data will be used only in statistical summaries and in no way will affect your recertification.

Gender:

MaleFemale

Race

African AmericanAsianHispanic

Native AmericanWhiteNo Response

I have read the Handbook for Candidates and understand I am responsible for knowing it's contents. I certify that theinformation given in this Application is in accordance with Handbook instructions and is accurate, correct, and complete.

CANDIDATE SIGNATURE: DATE:

Candidate Signature

Optional Information

Date (month/year):

ARE YOU CURRENTLY CERTIFIED BYEXAMINATION THROUGH NBCOPA?

J.

No YesIf yes, indicate month and year of expiration.

Eligibility and Background Information

Being board certified and a fellow of the American Academy of Orthopaedic Surgeons, I fully understand my responsibility as asupervising physician to this candidate. I hereby certifiy that I have read and understand the eligibility requirements for theCertification Examination for Orthopedic Physician Assistants. I acknowledge and attest that this candidate is an OrthopedicPhysican Assistant and has a minimum of five years of orthopedic experience in surgical assisting, history and physicalassessment, casting, and immobilization techniques. I agree to provide supervision and to accept full medical legalresponsibility for services provided in a hospital, clinic, or surgery center by this Orthopedic Physician Assistant.

TITLE:

Supervising Physician's Statement

STATE LICENSE NUMBER:

ADDRESS:

INSTITUTION: PHONE:

CITY/STATE:

NAME: SIGNATURE:

HAVE YOU TAKEN THIS EXAMINATION BEFORE?No Yes

If yes, indicate month, year, and name under which theexamination was taken.

I.

Name:

Date (month/year):

If you want to charge your application fee on your credit card provide all of thefollowing information.

Name (as it appears on your card):

Address (as it appears on your statement):

Charge my credit card for the total fee of: $

Card type:

Card Number:

Expiration date (month/year):

Signature:

Visa MasterCard American Express

/

FOR OFFICE USE ONLY

Fee:

CC Check

Date

CREDIT CARD PAYMENT

57665

certification examination for orthopedic physician assistants

Documents