Application Package

Provisional Practice
With Restrictions

September 2014

©2014 College of Physiotherapists of Ontario

Provisional Practice with Restrictions Application Package
Provisional Practice with Restrictions allows an individual the opportunity to practice after the first
unsuccessful completion of the clinical component of the Physiotherapy Competency Examination (PCE).
This requires increased levels of supervision and increased reporting to the College to ensure
public protection.

This package includes an information sheet, an application guide and form and the Plan and Agreement.

Section 1 Provisional Practice Information for Residents and Supervisors page 3

Section 2 Application for Registration Guide page 7

Section 3 Application Form (to be completed by Applicant) page 13

Section 4 Plan and Agreement (to be completed by Applicant and Supervisor[s]) page 25

For questions about registration and applying to the College, please contact:

Entry to Practice team

416-591-3828 ext. 222
or 1-800-583-5885 ext. 222
registration@collegept.org

College of Physiotherapists of Ontario

375 University Avenue, Suite 901, Toronto, ON M5G 2J5
Tel: 416-591-3828 or 1-800-583-5885 | Fax: 416-591-3834 | www.collegept.org

Provisional Practice with Restrictions Application Information Page 2

Provisional Practice with Restrictions Information for
Residents and Supervisors
Provisional Practice with Restrictions applies to Physiotherapy Residents who were unsuccessful in their first
attempt of the clinical component of the Physiotherapy Competency Exam (PCE), and may now continue to
practice under full and direct supervision. They must be registered in the next upcoming clinical component
of the exam. If the resident is unsuccessful at a second attempt at the clinical component of the PCE, the
Resident must stop practicing physiotherapy on or before the expiry date as shown on his or her certificate.
A Provisional Practice with Restrictions certificate will not be re-issued. If the Resident is successful at the
second attempt at the clinical component of the PCE, the individual must apply for an Independent Practice
certificate before the expiry date listed on their certificate of registration, to continue to practice.

An individual who is granted a Provisional Practice Certificate with Restrictions can practice as a Physiother-
apy Resident provided he or she receives full and direct onsite supervision from a physiotherapist holding an
Independent Practice Certificate. The Resident is issued a registration number entitling him or her to per-
form controlled acts if competent and rostered to do so, bill for physiotherapy services, and complete client
records. Physiotherapy Residents are accountable to the College for their actions.

To qualify for a certificate authorizing Provisional Practice with Restrictions, the Resident must

• successfully complete a degree in physiotherapy/physical therapy from a university in Canada or

have gained an academic qualification from outside Canada that is considered by the Canadian
Alliance of Physiotherapy Regulators as not substantially different
• successfully complete the written component of the Physiotherapy Competency Exam
• have attempted and not successfully completed the clinical component of the PCE on only one
occasion or been scheduled to do so and did not complete the exam as scheduled

To apply to the College for a Provisional Practice with Restrictions Certificate, the Physiotherapy Resident
must:

• submit a Provisional Practice with Restrictions Plan and Agreement that demonstrates that
they will have the full and direct supervision of a physiotherapist(s) with a current Independent
Practice Certificate while they are practicing and
• provide evidence that they are registered for the next available sitting of the clinical component
of the PCE.

Provisional Practice with Restrictions Application Information Section 1—Page 3

Provisional Practice with Restrictions Plan and Agreement
The Provisional Practice with Restrictions Plan and Agreement is a written contract between the Physio-
therapy Resident, the Supervisor and the College that outlines the responsibilities of both the Physiotherapy
Resident and the Supervisor. The Provisional Practice with Restrictions Plan and Agreement is prepared by
the Resident and Supervisor(s) and must be sent with the Provisional Practice with Restrictions application .

The Provisional Practice with Restrictions Plan and Agreement states that the Supervisor(s) will be on site at
all times and provide full and direct supervision when the Physiotherapy Resident is providing patient care.
Telephone contact does not constitute on-site supervision.

Physiotherapy Residents may have up to three supervisors as long as they meet the requirements and their
name is shown on a Provisional Practice with Restrictions Agreement.The primary supervisor will act as the
main contact for the College and oversee communication with all parties, ensure that the supervision plan is
followed, and will be responsible for the majority of the supervision of the resident.

The Agreement must be reviewed and approved by the College before the Physiotherapy Resident is allowed
to practice with Provisional Practice with Restrictions. The Agreement must include:

• a plan of onsite supervision including identification of all Supervisors;

• a plan to coordinate the supervision of the Physiotherapy Resident;
• a primary contact person—the Primary Supervisor; and
• mechanisms for providing supervision such as direct observation, review of documentation, case
reviews and meetings between the Physiotherapy Resident and Supervisor.

Supervisor’s Requirements and Responsibilities

The goal of Provisional Practice with Restrictions is to ensure that the Physiotherapy Resident practices and
delivers physiotherapy services that are safe, ethical and effective and that there is no undue risk of harm to
the public.

The Supervisor must:

• hold an Independent Practice Certificate and have a minimum of two years physiotherapy
practice experience.
• consider the time and the resources needed for full and direct supervision to determine their
ability to achieve the necessary level of supervision.
• be on-site at all times during which the Physiotherapy Resident is involved in direct patient care
activities.
• be able to provide observation and contact to ensure clinical competency. However, the
Supervisor is not required to be in the same room with the Physiotherapy Resident at all
times. Supervision via telephone is not considered to be on-site supervision. (The supervisor
does not have to be onsite if the Resident is involved in non-direct patient activities such as
documentation or research activities).

Provisional Practice with Restrictions Application Information Section 1—Page 4

 • include activities such as formal and informal observation, review of documentation, case
reviews, meetings with the Physiotherapy Resident and input from team members. Supervision
may also include chart audit, demonstration of skills, formal performance review or project
management.
• complete a formal evaluation of the Physiotherapy Resident using the Clinical Performance
Instrument (CPI) on dates provided by the College.
• immediately, within one business day, inform the Entry to Practice team of any professional
practices, incidents, conduct, incompetence or incapacity on the part of the applicant that may
affect patient care or public safety. Examples where contact with the College may be necessary
include (but are not limited to) committing a breach of confidentiality or privacy, crossing
boundaries, inappropriate billing, incapacity, a breach of the code of ethics, not seeking informed
consent or any behaviour or action that endangers the public safety.
• Supervise the Physiotherapy Resident’s clinical practice in order to evaluate and ensure clinical
competencies of the following:
• assessment;
• client goal setting;
• treatments;
• maintenance of client records and reports;
• the use of outcome measures;
• interaction and communication with clients and family;
• interaction and communication with other agencies and service providers;
• adherence to the Standards for Professional Practice and legislation.

Methods of Supervision may include:

• chart audit;
• videotape reviews;
• performance reviews; and
• peer reviews.

Provisional Practice with Restrictions Application Information Section 1—Page 5

Resident’s Requirements and Responsibilities
Before the restrictions period begins, the Physiotherapy Resident must:

• tell their employer of the expiry of his or her Provisional Practice certificate (if applicable) and
assist with interim arrangements to minimize disruption of care to patients;
• initiate discussion about the ability and willingness of the employer to provide full onsite
supervision and support to the Physiotherapy Resident in their application for Provisional
Practice with Restrictions;
• develop and complete a plan of supervision with the supervisor and employer;
• complete and submit all documentation related to the application for Provisional Practice with
Restrictions.

During the restrictions period, the Physiotherapy Resident must:

• ensure that all patients continue to be aware of their Physiotherapy Resident status and obtain
consent to treatment; and
• tell the College as to any changes to their practice or supervision and obtain College approval for
any proposed change to the Provisional Practice with Restrictions plan before the change occurs.

Joint Responsibilities
The Resident and the Supervisor will develop, maintain and comply with the Provisional Practice with
Restrictions Agreement and must ensure ongoing communication with the College.

The Provisional Practice with Restrictions Agreement must be completed and signed by the Supervisor(s)
and the Resident and submitted to the College before a Certificate for Provisional Practice with Restrictions
will be issued. Physiotherapy Residents must also include evidence that they have registered for the next sit-
ting of the clinical component of the Physiotherapy Competency Exam (PCE) with their application.

Provisional Practice with Restrictions Application Information Section 1—Page 6

Registration for Provisional Practice with Restrictions
Application Guide
The College of Physiotherapists of Ontario is pleased to provide this guide to help you complete your
application for an Provisional Practice with Restrictions certificate. Please review this guide prior to
completing your application form.

Practice Name
You are required to ensure that the name you use in practice is the same as the way that your name
appears on the Public Register. Your practice name will appear on the College’s Public Register.

The Public Register is a list of all currently registered and past registered physiotherapists in Ontario.
It provides the public with the physiotherapist’s information and history with the College and acts as
proof of registration for physiotherapists.

Previous Last Name

Enter your previous last name(s) if you have changed your name since completing your physiotherapy
education. If the name which you wish to register under is different than the name on your educational
qualifications or your immigration or citizenship documents, you must provide a photocopy of your
marriage certificate, divorce decree, or legal name change document.

Home Mailing Address

Please provide your home mailing address. The College will occasionally mail you important
information. The College does not provide your home address to any source outside the College, unless
you have indicated that this is also your business address. Please ensure that you provide complete
information.

Email Address
The College requires that all members have an active email address used for communication with the
College. Confidential information may be sent by email, so please ensure that the email address that
you provide is secure.

Language(s)
Indicate the languages in which you are capable of providing physiotherapy services. This information
will be provided to members of the public who are seeking physiotherapy services in a specific language.

You must also indicate the language in which you prefer to receive official documents. The College will
attempt to accommodate this preference whenever possible.

Provisional Practice with Restrictions Application Guide Section

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Education

Provide information about your initial physiotherapy education in this section. Include the name of the
educational program, the year of graduation, the academic institution and the location of the academic
institution (province/state if Canada or US and country).

If Provisional Practice with Restrictions is the inital certificate of registration with the College, you must
provide evidence of a degree in physiotherapy.

Please submit any one of the following:

• A notarized photocopy of your degree; or

• Arrange for notification to be sent directly to the College from the educational institution which
issued the degree (if the College is receiving a university list with your name on it, we would also
appreciate a photocopy of your degree to keep on file when it becomes available); or
• Bring your original degree to the College and entry to practice staff will photocopy it onsite
When you graduate from an Ontario university, a letter from the university outlining your completion of
the program will be sent to the College and will meet this requirement. You will still be required to provide a
photocopy of your degree when you apply for an Independent Practice certificate.

When asked to provide additional physiotherapy education and other education, please provide information
about any other formal education that you completed. The College does not require information about
continuing education programs or certifications. Only programs where degrees are granted should be
included in this section.

Eligibility to Work in Canada

To register with the College you must be legally eligible to work in Canada. This means you must provide one
of the following with your application:

1. Proof of Canadian Citizenship.

• A photocopy of your Canadian birth certificate, a photocopy of your Canadian passport
photo page or a photocopy of both sides of your citizenship card must be provided as proof
of Canadian citizenship.
2. Permanent Resident/Landed Immigrant of Canada
• A photocopy of your permanent resident card or document must be
included with your application.
3. A valid work permit
• A photocopy of your valid work permit indicating that you are eligible to work in
Canada must be included. This work permit must not prohibit you from working as a
physiotherapist.

Information about the Physiotherapy Competency Exam

For College registration purposes once the deadline for the examination application has passed, as published
by the Canadian Alliance of Physiotherapy Regulators, it is considered no longer available.

Provisional Practice with Restrictions Application Guide Section

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Registration, Licensure & Past Practice

You must tell the College of all of the places you have practiced physiotherapy. If the country is not regulated,
you must still provide us with the dates you practiced there. If the country is regulated you must provide us
with proof of registration/ licensure AND good standing. You can submit any one of the following:

• a letter of professional standing,

• verification of registration form, or
• by providing the College with a website address where the information can be verified online
Letters of professional standing must be dated within six (6) months of the application date.

Your Practice History in Physiotherapy

The College is required to provide de-identified information to the Ministry of Health and Long-Term Care
which is used for health human resources planning and to better understand labour mobility patterns.

Professional Conduct

If you answer YES to any questions, please provide further information. Your application will then be referred
to the Registration Committee for a decision related to your registration application. The College will contact
you to inform you of the process and what to do next.

Professional Liability Insurance

According to the College’s by-law on professional liability insurance, if you are going to provide patient
care, you are required to hold professional liability insurance. You must declare that you have or will have
professional liability insurance before you begin to provide patient care in Ontario.

Professional liability insurance should:

1. Be obtained individually or through your employer

2. Have a minimum coverage of $5 million for any one patient and for the policy year
3. Have no deductible

Patient Care
The College defines Patient Care as assessing people for physiotherapy needs, consulting with people,
and providing treatment in settings such as schools, companies, fitness centres, or institutions. It
includes weekend and relief work, and taking over when someone is on vacation. If you assign others to
work with patients, the College also considers this to be patient care. One interaction with one patient
per year is defined as patient care.

Provisional Practice with Restrictions Application Guide Section

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Information about Your Work Site
The College collects details about each work site that you are working at. This means that if you work for
one employer, but at two different work sites, you need to provide information about each location. This
information is made public on the College Public Register and must be accurate and up-to-date. You
must notify the College of any change to your employment within 30 days of the change happening.

Declaration
You must sign, check off and date the declaration section of the form in order for your application for
registration to be complete. The declaration confirms that all of the information you have provided in
the application is true and correct. If you provide incorrect or false information, you could be denied
registration or any registration issued to you could be revoked (taken away).

Provisional Practice with Restrictions Application Guide Section

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10
General Application Information
Incomplete Applications
Applicants who submit incomplete applications will be notified by email. A list of missing documentation
will be provided. You are welcome to submit your documents as they become available; however
applications will not be processed until they are complete. The processing time for applications
will not begin until the completed application, all additional documentation and fees have
been received.

Processing Time
The College will attempt to process your application for registration within ten business days of receiving
the completed application form and all required documentation. If you have pre-registered, your application
will be processed within five business days.

If there is doubt whether your application meets all of the registration requirements, it will be referred to
the Registration Committee for review. You will be contacted by College staff with more information
if your application is referred to the Registration Committee. Longer timelines will apply under these
circumstances.

Confirmation of Registration
An email will be sent to you to confirm your registration once your application has been processed.

Privacy
The personal information collected on this form is used by the College of Physiotherapists of Ontario for
its regulatory purposes (e.g., the registration and identification of College members, the administration
of statutes governing physiotherapists in Ontario and the administration of the College) and to develop
and provide statistical information for human resource planning, demographic and research studies and
eHealth Ontario. It is collected under the authority of the Regulated Health Professions Act, the Health
Professions Procedural Code, the Physiotherapy Act and the regulations and by-laws made under the
authority of these statutes. The College does not sell this information, nor does it provide the information to
commercial entities in a format that facilitates mass marketing. For more information about the Privacy
Code, please contact the College.

Document Retention
The College has moved to electronic maintenance and storage of member files. Electronic copies of
member applications and documents will be stored indefinitely. When you submit your application to the
College, if there are any hard copy documents that you would like us to return to you, please let us know.

Provisional Practice with Restrictions Application Guide Section

Section 1—Page
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11
Document Checklist
Please ensure that your application includes all of the following:

Provisional Practice with Restrictions Application Form

Signed Plan and Agreement

Written evidence from the Alliance confirming that you are registered in the next available clinical
component of the PCE

The appropriate fees

If you have never been registered before, you must also provide the following:
A photocopy of Canadian citizenship, permanent resident status or an authorization under the
Canadian Immigration Act to work in Ontario. You may submit a photocopy of any one of the
following:
• Proof of Canadian Citizenship
• Canadian birth certificate,
• Canadian passport photo page or
• both sides of your citizenship card
• Permanent Resident/Landed Immigrant of Canada
• A Valid Work Permit
Evidence of a degree in physiotherapy. Evidence includes any one of the following:
• A notarized photocopy of your degree; or
• Arrange for notification to be sent directly to the College from the educational institution which
issued the degree (if the College is receiving a university list with your name on it, we would
also appreciate a photocopy of your degree to keep on file when it becomes available); or
• Bring your original degree to the College and entry to practice staff will photocopy it onsite
A small photograph of you (either digital or printed)

If this applies to you:

Proof of registration/licensure and professional standing in all other jurisdictions where you have
been registered/licenced as a physiotherapist

A photocopy of your name change document

Provisional Practice with Restrictions Application Guide Section

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12
 Provisional Practice with Restrictions

APPLICATION FORM

This form is for all members who were unsuccessful at their first attempt of the Clinical Component or did not
complete the Clinical Component as scheduled. This category requires full and direct onsite supervision from a
supervisor and will involve the submission of the Clinical Performance Instrument.

1. Personal Information
Last name: ____________________________ Previous Last Name: ___________________________________
(if you had a different last name in the past, please provide it)

First name: ________________________________________ Middle name: ______________________________

Name you use to practice physiotherapy: _________________________________________________________

Home address: _____________________________________________________________________________

City/Town: _____________________________________________________________________________

Province: ______________________Country: ___________________________Postal code: _______________

Home telephone: __________________________________ Cell phone: ________________________________

Email: _____________________________________________________________________________________

Birth Date: ___________________________________ Gender:  Female  Male

(mm/dd/yy)

2. Language
I can provide physiotherapy services in: (choose all that apply)
 English  French  Other: _________________________________________________
I prefer to receive College documents in*: (choose one)
 English  French
*Communication is primarily in English and this selection will be accommodated for official documents only whenever possible.

FOR OFFICE USE ONLY

Date Received: _______________________ Date Complete: ______________________

Registration Date: _______________________ Registration Number: ______________________

Processed By: _______________________ Pre-Registered:  Yes  No

Professional Conduct: _______________________

Provisional Practice with Restrictions Application Form Section

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3. Education
3.1 Initial Physiotherapy Education
What is the initial physiotherapy education you completed?
Level of Education:
 Diploma  Baccalaureate  Masters  Professional Doctorate
 Other: ___________________________________________________ Year of Graduation: _______________

Name of Educational Institution: ________________________________________________________________

Province/State: ___________________________________ Country: ____________________________________

3.2 Do you have more Physiotherapy Education?

Starting with the most recent, please tell us about formal physiotherapy programs where you obtained a degree or
diploma after your initial physiotherapy education?
Level of Education: Level of Education: Level of Education:
 Baccalaureate 
Baccalaureate 
Baccalaureate
 Master 
Master 
Master
 Professional Doctorate 
Professional Doctorate 
Professional Doctorate
 Doctorate 
Doctorate 
Doctorate

Name of Educational Institution: Name of Educational Institution: Name of Educational Institution:

Province/State: ____ _ Province/State: Province/State:

Country: _____ Country: Country:
Year of Graduation: ___ Year of Graduation: Year of Graduation:

3.3 Education Other than Physiotherapy

Please tell us about other formal education where you obtained a degree or diploma. The College does not require
information about all continuing education courses.
GRS General Rehabilitation Science PHY Physical Sciences
MLS Medical Laboratory Science SAH Social Sciences, Arts and Humanities
HAM Health Administration/ Management EDU Education
PAD Public Administration LAW Law
PHE Public Health BMM Business, Management, Marketing and Related
KIN Kinesiology/Exercise Science MCI Mathematics, Computer Information Sciences
GER Gerontology ENG Engineering
PSY Psychology OSC Other Sciences
OHP Other Health Profession/Related Clinical Sciences OFS Other Field of Study
BBS Biological and Biomedical Sciences

*Field of Study— Please use the applicable 3 letter code in the above section

*Field of Study: *Field of Study: *Field of Study:

Level of Additional Education: Level of Additional Education: Level of Additional Education:
 Diploma  Diploma  Diploma
 Baccalaureate  Baccalaureate  Baccalaureate
 Master  Master  Master
 Professional Doctorate  Professional Doctorate  Professional Doctorate
 Doctorate  Doctorate  Doctorate

Provisional Practice with Restrictions Application Form Section

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14
 Name of Educational Institution: Name of Educational Institution: Name of Educational Institution:

Province/State: ____ Province/State: ____ Province/State: ____

Country: Country: Country:
Year of Graduation: ___ Year of Graduation: ___ Year of Graduation: ___

3.4 Educational Bridging Program

Did you complete an Ontario Bridging Program for Internationally Educated Physiotherapists?
 Yes If yes, what year:
Where:  Ryerson University  University of Toronto

 No

4. Information about the Physiotherapy Competency Exam

I have successfully completed the written component of the Physiotherapy Competency Examination (PCE).

Date of Completion: __________________________________________________________

I am registered in the next available clinical component of the PCE.

Date of Clinical: __________________________________________________________

I have attempted the clinical component of the PCE in the past.

Please provide the date(s): __________________________________________________

5. Registration, Licensure and Past Practice

5.1 Your practice of PHYSIOTHERAPY IN ONTARIO:
Have you ever been registered to practice physiotherapy in Ontario?
 Yes: I was registered from: _____________ to ____________ Registration number: ________________

 No

5.2 Your practice of PHYSIOTHERAPY OUTSIDE OF ONTARIO:

Have you ever practiced physiotherapy outside of Ontario?
 Yes: Please provide details about all locations, even if no professional licencing existed below.
 No
Province/State Country Licence/Reg. No. Dates

____________________ ________________________ _______________________ ____________________

____________________ ________________________ _______________________ ____________________

____________________ ________________________ _______________________ ____________________

Provisional Practice with Restrictions Application Form Section

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15
 5.3 Your practice in OTHER PROFESSIONS:
Have you ever been registered or licenced in any other regulated profession?
 Yes: Please provide details about all locations and regulated professions.
 No

Profession Province/State, Country Licence/Reg. No. Dates

____________________ ________________________ _______________________ ____________________

____________________ ________________________ _______________________ ____________________

____________________ ________________________ _______________________ ____________________

6. Your Practice History in Physiotherapy

By law, The College must provide general information about the physiotherapy profession to the Ministry of
Health and Long Term Care in Ontario. We do not give the Ministry your name or link your name to the answers
you provide below. You must answer these questions.

6.1 . Is Canada or the United States the first country where you have practiced physiotherapy?  Yes  No
a. If yes: Which province or state did you practice in?_________________________
What Year did you first register there?___________
b. If no: Where was the first Country you practiced? ____________________________________
What was the name of the province or state? ___________________________________
What Year did you first start? __________________________

6.2 Is Canada or the United States the most recent previous Country of practice?  Yes  No

a. If yes: Which province or state did you practice in?_________________________

When did you last practice?_________________________

b. If no: Where is the most recent previous country you practiced Physiotherapy?____________________
What was the name of the province or state? ___________________________________
Are you still practicing Physiotherapy or registered in this country?
 Yes If yes, what is the expiry date? ___________________________________
    No

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7. Professional Conduct
If you answer YES to any of the following questions please provide more information.

7.1 Have you ever had a finding of professional misconduct, incompetence or incapacity against you?

 No  Yes If Yes, Where? _____________________ When? ____________________

More information:

7.2 Have you ever had an application for a physiotherapy practice certificate or licence refused?

 No  Yes If Yes, Where? _____________________ When? ____________________

More information:

7.3 Have you ever had a physiotherapy practice certificate or licence suspended or taken away (revoked)?

 No  Yes If Yes, Where? _____________________ When? ____________________

More information:

7.4 Have you ever been found guilty of an offense, professional negligence or malpractice?

 No  Yes If Yes, Where? _____________________ When? ____________________

More information:

8. Professional Liability Insurance

Physiotherapists who provide patient care in Ontario must have professional liability insurance that meets the by-law
requirements. More information can be found in the Application Guide.
Please check the box that applies to you:
 I already have professional liability insurance OR
 I will have professional liability insurance before I begin patient care.

Provisional Practice with Restrictions Application Form Section

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9. Information about your Work Site
Please complete the employment information for each site where you will be working. Work site #1 is the site that you
are at most of the time. Each employment site must have a complete business address. All employment information is
public and will be available on the Public Register.
Do you work at more than three employment sites? Yes* No
*If yes, please attach additional pages and provide all required information about each site.

Work Site #1
Name of Work Site Start Date

Street Address

City Province/State

Country Postal Code/Zip Code

Business Phone No. Ext. Fax No.

Work Site #2
Name of Work Site Start Date

Street Address

City Province/State

Country Postal Code/Zip Code

Business Phone No. Ext. Fax No.

Work Site #3
Name of Work Site Start Date

Street Address

City Province/State

Country Postal Code/Zip Code

Business Phone No. Ext. Fax No.

Your Position Type Please choose only one per site.

First Site Second Site Third Site
Permanent Employee   
Temporary (Contract) Employee   
Casual Employee   
Employee (Other)   
Self-Employed   

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Which Do You Work? Please choose only one per site.
First Site Second Site Third Site
Full-time   
Part-time   
Casual   

Your Position or Job Title Please choose only one per site.
First Site Second Site Third Site
Manager   
Owner/Operator   
Service Provider   
Consultant   
Administrator   
Instructor   
Researcher   
Quality Manager   
Sales Person   
Other   

Describe Your Worksite Please choose only one per site.

First Site Second Site Third Site
Hospital   
Solo Professional Practice   
Group Professional Practice   
Rehabilitation Facility   
Residential/Long-Term Care Facility   
Visiting Agency/Business (Client’s Environment)   
Community Care Access Centre (CCAC)   
Post-Secondary Educational Institution   
Assisted Living Residence/Supportive Housing   
Community Health Centre (CHC)   
Family Health Team   
School or School Board   
Children’s Treatment Centre (CTC)   
Other Pediatric Facility   
Cancer Centre   
Mental Health and Addiction Facility   
Fitness Centre   
Association/Government/Regulatory or Similar   

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Board of Health or Public Health   
Telephone Health Advisory Services   
Health-Related Business/Industry   
Other Industry—Manufacturing and Commercial   
Spa   
Correctional Facility   
Nurse Practitioner Led Clinic   
Group Health Centre (Sault Ste. Marie only)   
Other   

What is the focus of your Practice? Please choose only one per site.
First Site Second Site Third Site
Clinical Focus on Musculoskeletal System   
Clinical Focus on Neurological System   
Clinical Focus on Cardiovascular & Respiratory System   
Clinical Focus on Skin & Related Structures   
Clinical Focus on More than One System   
Non-Clinical Focus   

What is the main area of Practice you are involved in? Please choose only one per site.

Patient Care: First Site Second Site Third Site

General Practice   
Sports Medicine   
Burns and Wound Management   
Plastics   
Amputations   
Orthopedics   
Rheumatology   
Vestibular Rehabilitation   
Women’s Health/Uro-genital   
Cancer Care   
Geriatric Care   
Chronic Disease Prevention and Management   
Cardiology/Cardiovascular   
Continuing Care/Long-Term Care   
Public Health   
Critical Care/ICU   
Mental Health and Addiction   
Neurology/Neuroscience   

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 Respirology/Cardio-respiratory   
Health Promotion and Wellness   
Palliative Care   
Return to Work Rehabilitation   
Ergonomics   
Other Area of Direct Service   
Infectious Disease Prevention and Control   
Emergency   
Other: Area of Practice
Client Service Management/Case Management   
Consultation   
Administration   
Teaching (Physiotherapy entry-level)   
Physiotherapy-Related Continuing Education Teaching   
Other Teaching   
Quality Management   
Research   
Sales   

What job sector do you work in? Please choose only one per site.
First Site Second Site Third Site
Public Sector   
Private Sector   
Combination of Public and Private   
Not Sure   

Main Category of Patients Please choose only one per site.

First Site Second Site Third Site

All Ages   
Pediatric   
Adult   
Geriatric   

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 Do you provide patient care? Please choose only one per site.
First Site Second Site Third Site
Yes   
No   
The College defines Patient Care as any component of assessment, analysis of findings or provision of treatments to patients
for whom you are directly responsible. This includes the assignment of any portion of care to support personnel.
Note: This includes roles involving assessment, consultation or provision of treatment in schools, industry, fitness centres, occasional
weekend or relief work or short-term vacation coverage. Even an interaction with one patient per year is defined as patient care.

Are you accepting new patients? Please choose only one per site.
First Site Second Site Third Site
Yes   
No   

This information will be used to assist the public in locating a physiotherapist.

In your main work site, do you prefer to work:

Full-time Casual
Part-time Not applicable

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 10. Fees
Please check the applicable amount in each section.

Application Fees Fee Check Selection

Application Fee (applies to new applicants) $100.00 

No application fee as I have held a certificate of registration with
the College that has terminated within the last year. – 

Registration Fees Fee Check Selection

Certificate of Registration Authorizing Provisional Practice with

Restrictions
$75.00 

Credit card payment (Please note: the College of Physiotherapists of Ontario does not accept Visa Debit)
 Visa  MasterCard Authorized payment amount: $

Card Number: Expiry Date:

Cardholder’s Name:

Cardholder’s Signature: _____________________

11. Additional Information

Please provide any additional information that you want the College to be aware of:

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12. Declaration
 I hereby certify that the statements made by me in this application are complete and correct
to the best of my knowledge and belief. I understand that a false or misleading statement may
disqualify me from registration or may be cause for any registration which may be granted
to me to be taken away (revoked).

 I understand that I must notify the College through the online registration system or in writing
by fax, email or mail of any change to my address, phone number or employment information
within thirty days of the change occurring.

 I understand that I must notify the College immediately of any change to my Plan
and Agreement.

Applicant Signature Date (mm/dd/yyyy)

Please note: The College maintains electronic copies of all application forms and submitted
documents indefinitely.

Please return this form to the College, by using any of the three methods below.
Hours of Operation: Monday–Friday (excluding statutory holidays) 8:30am–4:30pm
By mail or in person: By fax: By scanning and emailing:
College of Physiotherapists of Ontario 416-591-3834 registration@collegept.org
ATTN: Entry to Practice Associate
375 University Avenue, Suite 901
Toronto, ON M5G 2J5

Tel: 416-591-3828 ext. 222

Toll-free: 1-800-583-5885 ext. 222

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 ProvisionalProvisional
isional
Practice Practice
with Restrictions

PLAN AND AGREEMENT

This document must be submitted to the College before a Certificate of Provisional Practice with Restrictions
can be granted.

Name of Applicant: __________________________________________________________________________

PRIMARY SUPERVISING PHYSIOTHERAPIST

The Primary Supervisor is the physiotherapist who will provide the majority of supervision and complete all reports for the College.
When there is more than one supervisor involved, the Primary Supervisor will ensure coordination and ongoing communication between
all parties. The Primary Supervisor will be the main contact with the Resident, the College and any other supervisors.

Please provide the facility name, business address and telephone number of the site where the supervision will occur.

Facility Name

Facility Address Suite No.

City

Province/State Postal Code Facility Phone No.

Email Address

1.0 SUPERVISORS*

Supervisor First Name Supervisor Last Name Registration Number Estimated Hours of Supervision

Primary

Secondary

Tertiary**

* Supervisors must have a minimum of two years of physiotherapy practice experience.

** Typically there will be one Primary Supervisor who may be assisted by a second supervising therapist.
A third supervisor may be identified to support the supervision of a resident in the event of illness or vacation.

Provisional Practice with Restrictions Application—Plan and Agreement Section 4—Page 25

 ProvisionalProvisional Practice
Practice with Restrictions

PLAN AND AGREEMENT

2.0 OVERALL COORDINATION

If more than one Supervisor will be involved, describe how the Primary Supervisor will organize the overall coordination of
the supervision. Describe how the Primary Supervisor will ensure effective feedback and communication is maintained
between all parties.

3.0 SUPERVISION PLAN

Describe how you will supervise this Resident. Supervision must include the following activities; formal and informal
observation, review of documentation, case reviews, meetings with the Resident and input from team members.
Supervision may also include chart audit, demonstration of skills, formal performance review or project management.
Supervision requires that you (or another Supervisor) be onsite at all times when the Resident is involved in direct
patient care.

4.0 RESIDENT’S CASELOAD

Please describe the Resident’s caseload (e.g. orthopaedic, neurological) and the typical number of patients per day.

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APPLICANT
I, _____________________________________________________________, agree to comply with
the terms, conditions and limitations associated with a Certificate Authorizing Provisional Practice with
Restrictions. I agree that I shall only practice as a member of the College of Physiotherapists holding a
Provisional Practice with Restrictions Certificate while under the supervision of the person named in this
agreement and at the specified facility. I agree to assume responsibility for informing the College of any
proposed changes to the Provisional Practice with Restrictions Plan and understand that in the event that
either the supervisor or employment facility changes, I will be required to submit a new application, which
must be approved by the College before I can resume Provisional Practice with Restrictions. I understand
that I will use the title Physiotherapy Resident and that this Certificate for Provisional Practice with
Restrictions will not be re-issued.

Signature of Applicant Date (mm/dd/yyyy)

SUPERVISOR
I, _____________________________________________________________, agree to provide
supervision for the above named applicant in accordance with the Requirements and Responsibilities
specified by the College regarding Provisional Practice with Restrictions. I agree to comply with this
Provisional Practice with Restrictions Plan and understand that I am agreeing to directly supervise this
Physiotherapy Resident. As part of my supervisory responsibilities, I agree to formally evaluate the
Resident and will report (within one business day) to the College of Physiotherapists of Ontario any
professional practices, incidents, conduct, incompetence or incapacity on the part of the applicant
that in any way may adversely affect patient care or public safety. I will notify the College
immediately if I am unable to fulfill my responsibility as a Supervisor.

Signature of Primary Supervisor Date (mm/dd/yyyy)

If applicable:

Signature of Supervisor (2) Date (mm/dd/yyyy)

Signature of Supervisor (3) Date (mm/dd/yyyy)

Please return this form to the College, by using any of the three methods below.
Hours of Operation: Monday–Friday (excluding statutory holidays) 8:30am–4:30pm
By mail or in person: By fax: By scanning and emailing:
College of Physiotherapists of Ontario 416-591-3834 registration@collegept.org
ATTN: Entry to Practice Associate
375 University Avenue, Suite 901
Toronto, ON M5G 2J5
Tel: 416-591-3828 ext. 222
Toll-free: 1-800-583-5885 ext. 222

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