Site Approval Request CER

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]

Average number of cases per day*

Number of procedure rooms*

Number of endoscope reprocessors*

Number of sterilizers*

PLEASE LIST THE INFORMATION BELOW

Please provide the following information about your facility:

List the types of procedures performed at this facility*

List the methods of high-level disinfection/sterilization used*

List the mechanical endoscope cleaning equipment available (if applicable)*

List the types of sterile packaging materials available (if applicable)*

HANDS-ON EXPERIENCE CHECKLIST

Please provide information specific to your facility on how it provides the hands-on experiences required for the CER 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:

Pre-cleaning*

Testing*

Decontaminating*

Inspecting*

Disinfecting and/or sterilizing*

Transporting*

Drying*

Storing endoscopes*

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.