NBAOS - National Board of Accreditation for Orthotic Suppliers

Surveyor Application

Complete the following surveyor application. Once completed, you will attach your CV or resume and notification of any legal action or malpractice. Instructions for uploading the documents to NBAOS are outlined at the end of the application.

PERSONAL INFORMATION
First Name:
Middle Initial:
Last Name:
Credentials:
Home Address  
Street Address:
Street Address Continued:
City:
State:
Zip Code:
Phone:
   
Email - Home:
(Email notification will be sent
to this email address)
Email - Work:
   
Work Address  
Name of Facility:
Street Address:
Street Address Continued:
City:
State:
Zip Code:
 
CURRENT WORK SETTING & RESPONSIBILITIES   
 

Check all that apply:

Private Practice  
Physician Owned Practice
Outpatient Rehabilitation Facility
Other
If Other selected - please specify:
   
Staff Therapist
Senior Level Staff Therapist
Supervisor, Manager, Director
Owner
Other
If Other selected - please specify:
 
CURRENT STATE LICENSURE INFORMATION
License 1  
Name :
(as it appears on license) 
 License #:
State:
   
License 2  
Name:
(as it appears on license) 
 License #:
State:
 

Have you had any legal action or malpractice suits brought against you? Yes No
If yes, what was the outcome? Please include a document explaining the legal action using the upload option below.
 
PREVIOUS WORK HISTORY
(include addresses of any positions held in the last 3 years):
Facility 1  
Facility Name:
Facility Address - Street:
Facility Address - City:
Facility Address - State:
Facility Address - Zip Code:
Facility Phone Number:
Facility Contact:

Facility Email Address:
Start Date:
End Date:
Hours/Week:
   
Facility 2  
Facility Name:
Facility Address - Street:
Facility Address - City:
Facility Address - State:
Facility Address - Zip Code:
Facility Phone Number:
Facility Contact:

Facility Email Address:
Start Date:
End Date:
Hours/Week:
   
Facility 3  
Facility Name:
Facility Address - Street:
Facility Address - City:
Facility Address - State:
Facility Address - Zip Code:
Facility Phone Number:
Facility Contact:

Facility Email Address:
Start Date:
End Date:
Hours/Week:
   

Additional work history information
as necessary:
   

ORTHOTICS KNOWLEDGE – FABRICATION & DISPENSING OF ORTHOSES
Describe below your level of knowledge and expertise in orthotics:

 

ADDITIONAL INFORMATION
Please provide any additional information explaining how you would be an excellent NBAOS surveyor?

 

GEOGRAPHIC AREA INTERESTED IN PERFORMING ONSITE SURVEYS:
Specific cities
Specific area of state:
Specific state(s)
No preference – willing to travel throughout the country

TERMS OF AGREEMENT
1. Do you understand and agree to the required deadlines for on-site surveys and reports? Yes No
 
2. Do you understand it will be necessary for you to have access to a computer for electronic submission of survey results? Yes No
 

3. Do you understand you will need to sign a “Confidentiality Agreement” and a “Conflict of Interest” document? Yes No
 
4. Do you understand you will have to undergo and complete a surveyor training session on conducting surveys prior to achieving surveyor status.  In addition, do you understand I must attend an annual training session to maintain my surveyor status. Yes No
 
5. Do you understand and agree that you may be called as a witness by CMS in an adverse action against a facility? Yes No
 
6. Do you agree to serve for a minimum of two years as a surveyor?
Yes No
 

7. I affirm I do not have any criminal history.
Signature:
Date:
8. I affirm I do not have any current legal action filed against me.
Signature:
Date:
9. I affirm that I do not have any malpractice filed against me.
Signature:
Date:
10. I affirm I am currently in good standing with CMS.
Signature:
Date:
11. I attest, to the best of my knowledge, that all information in this application is accurate.
Signature:
Date:
 
CONFLICT OF INTEREST

National Board of Accreditation for Orthotic Suppliers
Conflict of Interest Guidelines

It is understood that surveyors may encounter instances where there is a conflict of interest.  In response to that possibility, NABOS has established the following guidelines.

1.  A surveyor will not participate in the accreditation process of any organization/facility in which he has a financial interest.

2.  A surveyor will not participate in the accreditation process of any organization/facility in which he has an immediate family member (i.e. spouse, significant other, child, parent, or sibling of surveyor).

3.  A surveyor will not participate in the accreditation process of any organization/facility in which he has applied for a position, or been employed at, over the last 3 years.

4.  A surveyor will not participate in the accreditation process of any organization/facility in which he deems that he may be in competition with.

5.  A surveyor will not participate in the accreditation process of any organization/facility which has a substantial contractual relationship with the surveyor and/or the surveyor’s place of employment.

6.  A surveyor will not act as a consultant to the accreditation (with the exception of advice on the accreditation process itself) to any other facilities applying for accreditation with NAOBS.

7.  A surveyor will not participate in the accreditation process of any organization/facility that has identified that surveyor as someone in conflict with that organization.

8.  NBAOS has the discretion to deem other relationships a conflict of interest when not expressly defined above.

I have read the above policy on conflict of interest, and agree to follow those guidelines.

Signature:
Date:
 
CONFIDENTIALITY GUIDELINES

National Board of Accreditation for Orthotic Suppliers
Confidentiality Guidelines

All employees, independent contractors and volunteers of the National Board of Accreditation for Orthotic Suppliers (NBAOS) may have access to confidential information from clinics, facilities and personnel of applicants. It is critical that this information be treated with the confidentiality it deserves. For purposes of these Guidelines, Confidential Information includes, but is not limited to, any information considered to be Protected Health Information (“PHI”) under HIPAA privacy regulations, financial and pricing information, all books, manuals, documents, materials, business or technical information, trade secrets, systems, strategies, policies and procedures and all other information concerning the applicant’s business, contractual relationships with facilities, payors and other healthcare providers, and plans or policies related to the applicant or its patients that is (i) not otherwise available to the public, (ii) divulged to NBAOS by a person subject to obligations of confidentiality, or (iii) not required to be divulged pursuant to an administrative or court order or otherwise pursuant to applicable law.

NBAOS and its employees, contractors and agents shall not, directly or indirectly, disclose to any person or entity, other than its employees, agents or independent contractors engaged by NBAOS, any Confidential Information regarding its applicants, except as specifically authorized by the applicant and/or required by applicable law. NBAOS reserves the right to disclose information on current accreditation status and history, dates of surveys, and status of accreditation process as necessary for CMS. Violation of these Guidelines is grounds for immediate dismissal or removal from an BNBAOS position. In addition, licensure boards may be contacted relating to unethical behaviors, as deemed appropriate by the Board of Directors of NBAOS. Additionally, NBAOS requires the completion of the statement below as acknowledgement of the obligations stated in these Guidelines.

I acknowledge that information obtained from the accreditation process of NBAOS, including, but not limited to, patient PHI, records of employees, policies and procedures, financial information, and disciplinary actions are confidential in nature. As such, disclosure or distribution of Confidential Information through any means, including any written or oral form, is strictly prohibited. Illegal access or misuse of Confidential Information is grounds for immediate dismissal, and may incur further legal and/or licensure action.

Signature:
Date:
 
SURVEYOR JOB DESCRIPTION

National Board of Accreditation for Orthotic Suppliers
Surveyor Job Description

INTRODUCTION
The NBAOS surveyor plays a vital role in the success of the accreditation program for NBAOS. The NBAOS surveyor is the only individual the supplier will meet in person during the accreditation process. This alone makes the role of surveyor particularly important. In complement to this, the surveyor makes numerous important decisions during an onsite survey which ultimately determines whether or not a supplier is granted accreditation. Since all suppliers interested in dispensing durable medical equipment, prosthetics and orthotics (DMEPOS), and billing through a DME # granted by the National Supplier Clearinghouse, must be accredited in the near future, it is vital for suppliers to seek accreditation. Therefore, the objective decisions of the surveyor are extremely important to all suppliers. NBAOS views the role of the surveyor as instrumental to maintaining the high accreditation standards established by CMS and NBAOS and ensuring an objective and professional survey.

APPLICATION PROCESS
Occupational therapists and physical therapists may apply to serve as a contractor with NBAOS as a surveyor. The prospective surveyor must complete the NBAOS surveyor application and submit the application to NBAOS for review. The surveyor review committee will review all prospective surveyor applications and determine the strongest candidates for the positions. The selected surveyors will serve a two year term as surveyor. Applications are available through NBAOS. Successive terms are permissible.

JOB SUMMARY
A site surveyor is responsible for surveying facilities seeking accreditation by NBAOS. The primary responsibilities include: traveling to facilities, performing onsite surveys, completing the accreditation survey form, submitting the survey data to NBAOS, and offering guidance and recommendations to the facility, as needed. Surveyors must have their own transportation, laptop computer with basic computer skills, excellent communication skills, a professional demeanor, ability to schedule days for onsite surveys within a 60 day timeframe, develop the knowledge base to perform the onsite surveys through learning with a training manual and/or attendance of a NBAOS surveyor training program and successfully pass the surveyor training self-assessment.

JOB RESPONSIBILITIES

  1. All surveyors will undergo initial surveyor training by NBOAS prior to being assigned any sites and will complete an annual training review course which when available may be completed online. NBAOS may require surveyors to undergo re-training if complaints are received from surveyed facilities.
    2.
  2. The surveyor will be given a facility to perform an onsite survey. The surveyor will have 10 business days to determine a date within the 60 days from receipt of the onsite survey fee to schedule the survey with NBAOS. If, for any reason, the surveyor cannot conduct the survey NBAOS is to be notified within two business days of the assignment.
    3.
  3. The surveyor will complete the unannounced survey within 60 days of the assignment from NBAOS to conduct the survey.
    4.
  4. The surveyor will complete the survey in a professional and confidential manner, with consideration given to the daily patient care and any other business occurring within the facility.
    5.
  5. The surveyor will address any questions presented by the facility. In those instances where the surveyor cannot answer the question, the surveyor will contact NBAOS and subsequently follow up with the facility to answer the question.
    6.
  6. The surveyor will leave the NBAOS evaluation form with each facility to complete and submit back to NBAOS.
    7.
  7. The surveyor will be notified of any unfavorable comments or concerns reported by the facility.
    8.
  8. The surveyor will submit to NBAOS, via email, the onsite survey results within two business days of the survey.
    9.
  9. The surveyor must have access to a personal computer, the technical competency to complete the survey and submit the survey findings to NBAOS.
    10.
  10. The surveyor will comply with all NBAOS policies and procedures, including confidentiality guidelines and conflict of interest policies.
    11.
  11. The surveyor will comply with all CMS and NBAOS guidelines for accreditation and quality standards.
    12.
  12. The surveyor will wear business casual attire for the onsite surveys.
    13.
  13. The surveyor will serve as a witness, if deemed necessary by CMS.
    14.
  14. The surveyor understands complaints by facilities, or by NBAOS, may result in termination of the contracted services.
    15.

I have read the above NBAOS Surveyor Job Description and accept all duties this position entails.
Signature:
Date:
 
INFORMATION TO SUBMIT WITH APPLICATION

Please upload the following documents using the upload function below. If you experience any difficulty uploading your documents please contact Allison Cline at 888 463 4011 or acline@smithbucklin.com.

  1. A current copy of your curriculum vitae (CV) or professional resume; including work experience, education, degrees received, specialty certifications, continuing education, presentations, published peer reviewed articles, chapters or books, committee and/or officer experience with ASHT, AOTA, APTA, or any other medical professional organization. Please denote any continuing education, presentations taught, research completed or publications published specifically in orthotics.

    2.
  2. A copy of your license/registration/certification to practice as an occupational therapist or physical therapist in the United States.

  3. Any legal action or malpractice suits brought against you (if applicable).

  4. A copy of your HTCC certificate.
    5.
 
UPLOAD DOCUMENTS
Browse to file on your computer:
File name of uploaded document:
ENTER THE FILE NAME WITH EXTENSION ONLY
Example: docname.doc or docname.pdf

Directions to Upload document with this online application:
1. Have word doc or pdf saved on your computer with NO spaces in it's filename.
2. Click the Browse... button
3. Browse and select your document via the pop up window.
4. Once you highlight/select the filename - the filename should now be displayed in the pop up window's File Name box. Make note of this file name - you will need to enter it in the next field.
5. Click Open - the pop up window will disappear and the file to be uploaded will now appear in the field next to the Browse button.
6. In the next field - File name of uploaded document - type in the filename only of the document you just selected.
7. Once all data has been entered click submit. This will upload the document for submission with this application.