Site Approval Request CRCST/CIS

HSPA defines a traditional hands-on experience clinical site as a hospital or an ambulatory surgery center. Occasionally, applicants for certification request to obtain their hands-on experience at a non-traditional site such as a dental or optical facility, a clinic procedure area, or a veterinary practice.

All requests for the use of a non-traditional site must be approved by HSPA before time is scheduled at the site.

The process is as follows:

Before beginning the hands-on experience, the applicant should submit the form below.
The application will be reviewed to determine if the site has the capability of providing all the required hands-on experiences.
The applicant will be notified of the approval status (accept/reject).

Incomplete applications will not be processed.

APPLICATION FORM

I certify that the information provided by and about me on this form (and any other subsequent documentation submitted in relation to my certification) is accurate and correct. I understand that the information I provide to HSPA may be audited for verification. I agree to provide any information necessary to verify my experience and authorize HSPA to make any necessary inquiries in this regard. I understand that providing information on this or any document relating to my certification which is determined to be false or purposefully misleading, or in violation of any portion of the Code of Conduct and/or other policies and procedures, may result in disciplinary action, including the possible denial or revocation of certification, as outlined in the disciplinary policy.

Select the credential you wish to obtain*

Today's Date*

APPLICANT INFORMATION

First Name*

Last Name*

Applicant's Street Address*

Applicant's City*

Applicant's State*

Applicant's Zip Code*

Applicant's Country (if outside the US)

Applicant's Email*

Applicant's Phone*

FACILITY INFORMATION

Please provide the following information about your facility:

Other (Please specify type of facility*

Name of Facility*

Facility Street Address*

Facility City*

Facility State*

Facility Zip Code*

Facility Country (if outside the US)

Facility Website*

Facility Contact (First and Last Name)*

Facility Contact's Email[*Must be a business email address]

Facility Contact's Phone[*Must be a business phone number]

How large is the facility?*SmallMediumLarge

Average number of cases per day*

Number of procedure rooms*

Number of sterilizers*

PLEASE LIST THE INFORMATION BELOW

Please provide the following information about your facility:

List the types of surgical procedures performed at this facility*

List the methods of Sterilization used*

List the mechanical cleaning equipment available*

List the types of sterile packaging materials available*

HANDS-ON EXPERIENCE CHECKLIST

Please provide information specific to your facility on how it provides the hands-on experiences required for the CRCST or CIS examination. We ask you briefly descript the facility's steps or procedures for completing each of the items below, as it relates to instrument reprocessing. Each answer should be specific to the task listed:

Decontamination processes including equipment quality control testing and functionality checks, selection and use of solutions and manual cleaning implements, mechanical cleaning*

Preparing and packaging instruments including identification, inspection, and testing of instruments, selection and inspection of packaging materials and tray assembly*

Sterilization and disinfection including any high-temperature and low temperature sterilization processes, record keeping, automated and manual disinfection and troubleshooting equipment failures (failed cycles, wet loads, repairs)*

Storage and distribution, including handling and storage of sterile trays and supplies, inventory management, expiration dating and event related sterility and cleaning of storage shelves.*

Quality assurance processes, including standards and regulations, documentation and record keeping, routine maintenance of equipment and equipment tracking.*

This commitment to advancing Sterile Processing (SP) knowledge, skill sets and professionalism is why over 61,000 members and certification holders rely on HSPA to keep them sharp, focused and abreast of the very latest standards, best practices and technological advancements impacting the SP profession.