Role Delineation Study/ Practice Analysis, 6th...

Role Delineation Study/Practice Analysis, 6th Edition

Effective for April 2011 Exam andJanuary 1, 2012 Continuing Education

Certainty in the Professional Practice of Athletic Trainers

Includes Complete Survey Tool and Bibliography

Athletic Trainer Role Delineation/Practice Analysis Study

for the Entry‐Level Certified Athletic Trainer

BOC 2010: Athletic Trainer Role Delineation/Practice Analysis Study

Report of Findings from the 2009 Athletic Trainer Role Delineation/Practice Analysis Study

Document prepared by:

Stephen B. Johnson, Ph.D. Senior Psychometrician Castle Worldwide 900 Perimeter Park Drive, Suite G Morrisville, NC 27560 USA

www.castleworldwide.com Copyright © 2010 Board of Certification (BOC)

All rights reserved. The BOC logo and “Be Certain” are registered trademarks of the BOC and this document may not be used, reproduced, or disseminated to any third party without written permission from the BOC. Non‐profit education programs have permission to use or reproduce all or parts of this document for educational purposes only. Use or reproduction of this document for commercial or for‐profit use is strictly prohibited. Any authorized reproduction of this document shall display the notice: “Copyright by the Board of Certification, Inc. All rights reserved.” Or, if a portion of the document is reproduced or incorporated in other materials, such written materials shall include the following credit: “Portions copyrighted by the Board of Certification, Inc. All rights reserved.” Address inquiries in writing to Board of Certification, 1415 Harney St. Suite 200, Omaha, NE 68102. Suggested Citation: Board of Certification. (2010). The 2009 Athletic Trainer Role Delineation Study. Omaha, NE: Stephen B. Johnson.


TABLE OF CONTENTS Page

Executive summary ............................................................................................................................................... 1

Review of the existing task list ....................................................................................................................... 1

Panel of subject matter experts ..................................................................................................................... 1

Survey development ...................................................................................................................................... 1

Survey process ............................................................................................................................................... 2

Sample selection ..................................................................................................................................... 2

Representativeness ................................................................................................................................. 2

Contact procedures ................................................................................................................................. 2

Return rates............................................................................................................................................. 2

Demographics and work experience .............................................................................................................. 2

Task and domain analysis findings ................................................................................................................. 2

Reliability of ratings ................................................................................................................................. 2

Criticality ................................................................................................................................................. 2

Frequency ................................................................................................................................................ 3

Importance .............................................................................................................................................. 3

Summary ........................................................................................................................................................ 3

Conclusion ...................................................................................................................................................... 3

Study purpose ....................................................................................................................................................... 4

Some important definitions ........................................................................................................................... 4

Methodology ........................................................................................................................................................ 6

Review of existing role delineation/practice analysis outline ....................................................................... 6

Panel of subject matter experts (SMEs) ........................................................................................................ 6

Panel background information ............................................................................................................... 7

Initial instructions and definitions for the panel..................................................................................... 7

Defining the tasks and domains .............................................................................................................. 8

Development, response rates, and representativeness of the survey respondents ......................................... 11

Questionnaire design and distribution ........................................................................................................ 11

Response rates ............................................................................................................................................. 11

Representativeness of sample ..................................................................................................................... 11

Demographics and professional experiences of the survey respondents ................................................... 15

Demographics ....................................................................................................................................... 16

Professional experience ........................................................................................................................ 18


Practice settings .................................................................................................................................... 19

Validation of tasks and domains ......................................................................................................................... 24

Defining the criticality measure ................................................................................................................... 24

Defining the frequency measure ................................................................................................................. 24

Defining reliability of the measures used .................................................................................................... 24

Criticality and frequency measures for domains ......................................................................................... 24

Criticality and frequency ratings for tasks ................................................................................................... 25

Reliability of criticality and frequency ratings ............................................................................................. 27

Defining the importance weight .................................................................................................................. 28

Development of the proposed test blueprint .................................................................................................... 31

Capping the tasks rated low in importance ................................................................................................. 31

Calculating the remaining 21 tasks .............................................................................................................. 31

Flexibility in the proportion assigned to a task ............................................................................................ 31

Approval by the BOC .......................................................................................................................................... 33

References .......................................................................................................................................................... 34

Appendices ......................................................................................................................................................... 35


TABLES

Table 1: Summary statistics of ratings of item writing difficulty and resulting confidence intervals for 15 BOC item writers of existing 37 tasks, September 2008. ....................................................................................... 6

Table 2: Twenty‐eight tasks identified by subject matter experts for athletic trainers, October 2008. ....................... 8

Table 3: Domains identified by subject matter experts for athletic trainers, October 2008. ..................................... 10

Table 4: Number and percentage of respondents, requests, and members sent to six U.S. regions, BOC athletic trainer validation survey, March‐April 2009. .......................................................................................... 12

Table 5: Mean, Standard Error of the Mean, and Standard Deviation of the number of years certified for respondents, requests, and members, BOC athletic trainer validation survey, March‐April 2009. .................... 13

Table 6: Number and percentage of respondents, requests, and members for each of 18 practice settings, BOC athletic trainer validation survey, March‐April 2009. ........................................................... 14

Table 7: Number and percentage of respondents, by age group, BOC athletic trainer validation survey, March‐April 2009. ........................................................................................................................... 16

Table 8: Number and percentage of respondents, by ethnicity, BOC athletic trainer validation survey, March‐April 2009. ........................................................................................................................................ 18

Table 9: Number and percentage of respondents, by highest level of education earned, BOC athletic trainer validation survey, March‐April 2009. ............................................................................................... 18

Table 10: Number and percentage of respondents, by years practicing, BOC athletic trainer validation survey, March‐April 2009. ........................................................................................................................... 18

Table 11: Number and percentage of respondents by other health care credential held, BOC athletic trainer validation survey, March‐April 2009. ............................................................................................... 22

Table 12: Number and percentage of respondents by position title, BOC athletic trainer validation survey, March‐April 2009. ........................................................................................................................... 23

Table 13: Number of survey respondents and percentage for criticality and frequency ratings for five domains, BOC athletic trainer validation survey, March‐April 2009. .......................................................... 25

Table 14: Number and percentage of survey respondents for criticality and frequency ratings for 28 tasks, BOC athletic trainer validation survey, March‐April 2009.................................................................................... 26

Table 15: Number of survey respondents and tasks, and associated Cronbach’s alpha for criticality and frequency ratings for tasks within five domains, BOC athletic trainer validation survey, March‐April 2009. ..................................................................................................................................................................... 28

Table 16: Number of survey respondents and average and standard deviation of importance weight for 28 tasks and five domains, BOC athletic trainer validation survey, March‐April 2009. ............................................ 29

Table 17: Description and proportion of items for the BOC athletic trainer examination. ......................................... 32


FIGURES

Figure 1: Five U.S. regions for respondents, BOC athletic trainer validation survey, March‐April 2009. .................... 12

Figure 2: Proportion of each of three groups (Members, Requests, and Respondents) in 18 professional settings, BOC athletic trainer validation survey, March‐April 2009. .................................................................... 15

Figure 3: Histogram of respondent ages at the time of the survey, BOC athletic trainer validation survey, March‐April 2009. ................................................................................................................................................ 17

Figure 4: Histogram of respondent ages at the time of the certification, BOC athletic trainer validation survey, March‐April 2009. .................................................................................................................................... 17

Figure 5: Graph for 1,152 respondents of the number of years certified at the time of the survey, BOC athletic trainer validation survey, March‐April 2009. .......................................................................................... 19

Figure 6: Graph for 1,152 respondents of the percent of work time spent as an athletic trainer, BOC athletic trainer validation survey, March‐April 2009. .......................................................................................... 20

Figure 7: Graph for 1,152 respondents of the number of athletic trainers or other health care professionals supervised, BOC athletic trainer validation survey, March‐April 2009. ......................................... 20

Figure 8: Graph for 1,152 respondents of the annual income earned as an athletic trainer, BOC athletic trainer validation survey, March‐April 2009. ....................................................................................................... 21

Figure 9: Graph for 1,152 respondents of their reported practice settings, BOC athletic trainer validation survey, March‐April 2009. .................................................................................................................................... 22


APPENDICES

Appendix A: Classification system of domains, tasks, and knowledge and skill statements ....................................... 35

Appendix B: Average ratings of writing difficulty for 15 BOC item writers, September 2008..................................... 92

Appendix C: Attendees of the October 2008 subject matter panel meeting .............................................................. 95

Appendix D: Background of the October 2008 subject matter panel meeting ........................................................... 96

Appendix E: Workbook used for the October 2008 subject matter panel meeting .................................................... 98

Appendix F: Survey tool used for BOC athletic trainer role delineation study, March‐April 2009 ............................ 111

Appendix G: E‐mail requests sent to potential survey respondents ......................................................................... 129

Appendix H: Number and percent of persons from each U.S. state for members certified 3 to 7 years, members sent requests, and members who responded to the validation survey, April 2009 .......................... 131

Appendix I: Criticality statistics for BOC domains and tasks...................................................................................... 133

Appendix J: Frequency statistics for BOC domains and tasks .................................................................................... 134

Appendix K: Correlations for ratings of frequency and criticality for five domains .................................................. 135

Appendix L: Correlations for ratings of frequency and criticality for 28 tasks .......................................................... 136

BOC 2010: Athletic Trainer Role Delineation/Practice Analysis Study 1

EXECUTIVE SUMMARY

The Board of Certification (BOC) is a not‐for‐profit certifying body for individuals with education and experience in the practice of athletic training. As with other certification programs, the BOC’s program aims to establish that individuals have the knowledge and skills necessary to perform tasks critical for the safe and competent practice as an entry‐level athletic trainer

In 2008, the BOC began the process of reviewing the test blueprint for the BOC Athletic Trainer Examination. The BOC worked with Castle Worldwide, Inc., a certification and licensure design, development, and administrative service company, to ensure that its certificate examinations meet guidelines and standards for examination development (e.g., Standards for Educational and Psychological Testing, American Educational Research Association, 1999; Uniform Guidelines on Employee Selection Procedures, EEOC, 1978).

A number of steps were undertaken for the analysis of the practice requirements for newly certified athletic trainers. First, feedback was obtained from the existing BOC examination item writers, exam development personnel, and a review of feedback from candidates and other persons to identify task areas on the existing athletic trainer test content outline that were problematic. A panel of subject matter experts (SMEs) was then assembled. The panel reviewed the existing material and feedback and developed a list of athletic trainer activities that was incorporated into a survey sent to a randomly selected sample of athletic trainers, and the data was collected and analyzed.

Review of the existing task list

The existing test content outline developed in the 2004 role delineation/practice analysis study consists of 37 tasks in six domains.

A review of candidate comments and discussions with test and exam development personnel identified problems with some of the existing tasks in terms of the ability to write meaningful and valid questions. A survey was conducted of existing item writers asking

them to rate on a scale of 1 (None) to 4 (A great deal) how difficult they found writing items to the task to be. Tasks with low ratings were less difficult to write to than tasks with high ratings. A total of 15 item writers provided ratings on the 37 tasks.

The average rating for each task and the 99% Confidence Interval (CI)i was calculated. The average ratings ranged from 1.43 to 2.73, with an average of 1.89. Eight tasks had ratings above 2.13 (the 99% CI), indicating that the item writers had significant difficulty writing items for these tasks. This included all the tasks for Domain 5 (Organization and Administration). These eight tasks were flagged for special review in the next phase.

Panel of subject matter experts

A 23‐member panel of subject matter experts was assembled to develop an outline of the areas of practice required for competent performance as a newly certified athletic trainer. The panel members worked with or supervised the practice of recently certified athletic trainers or had been certified within the last three to seven years. Panel members represented a variety of geographic areas in North America and varied practice settings.

The panel members initially reviewed the existing role delineation/practice analysis task statements and the tasks identified by the initial process as problematic. Based this review and their own experiences, the panel members created a list of 28 core tasks they identified as essential for competent and safe practice. The panel then categorized these tasks into five domains of practice and developed a series of knowledge and skill statements for these tasks.

Survey development

A total of 33 athletic trainer statements (28 tasks and five domains) were incorporated into the role delineation/practice analysis survey. The survey also included a number of questions about the athletic trainer’s practice settings, work experiences, and demographics. The entire survey was conducted online.


The survey was reviewed by members of the BOC staff, Castle staff, and a subset of the SME panel to ensure fidelity with the panel’s work as well as appropriate survey design.

Survey process

Sample selection

The BOC provided a list of 7,255 BOC certified athletic trainers who had been certified between three to seven years as of October 2008. From this list, a total of 5,003 athletic trainers were randomly selected.

Representativeness

The sample selected for this study was proportionally equivalent to the 7,255 BOC certified athletic trainers in terms of geographic locations. The survey respondent sample was also equivalent in the number of years certified and very similar in the practice settings to the larger group.

Contact procedures

A series of e‐mail requests were developed by Castle staff and reviewed by BOC staff. The potential respondents were contacted by e‐mail on a prescribed schedule. All potential respondents were promised confidentiality regarding their participation and responses. Data was collected and analyzed by Castle staff and summary results provided to the BOC. The survey was conducted from March 16 through April 15, 2009.

Return rates

Of the 5,003 requests sent, a total of 1,152 respondents started the survey, an overall response rate of 23%. This response rate is similar to experiences with other role delineation/practice analysis/practice analysis surveys.

Not all individuals responded to every question or provided valid responses; therefore, the total number of responses per question varied. For example, the last task statement was rated by a total of 973 respondents, 84% of those who began the survey. Experience with similar surveys show a completion rate typically between 75% and 85%.

Demographics and work experience

As noted earlier, the survey respondents were representative of BOC certified athletic trainers who had been certified within three to seven years. They represented all regions of the U.S. and had a median age of 29. The median age at certification was 23, and most persons had been practicing less than five years.

The majority of respondents were female (59%), Caucasian (90%), and had a Master’s degree (65%).

The annual income for most respondents was in the $30,000 to $49,999 range, and the largest group worked as athletic trainers in secondary education (28%). Fifty‐seven percent of the respondents spent 75% or more of their work time as an athletic trainer, and 72% did not supervise any other athletic trainer or other health care professional. Seventy percent of the responses indicated that the BOC certification was their only professional certification. Finally, 71% of the respondents indicated that their job title was either “Athletic trainer” or “Head athletic trainer.”

Task and domain analysis findings

Reliability of ratings

Reliability indices were calculated to assess the capability of the survey to measure the activities relevant to safe and effective practice of newly certified athletic trainers. The scales used had reliability indices above 0.7 for the ratings of task criticality and frequency, which is very good. These high reliability indices indicate the survey is reliably measuring the activities necessary for competent athletic trainer practice.

Criticality

Criticality was defined as:

The degree to which workers, clients, a member of the public, or other stakeholders would be physically, emotionally, or financially harmed if the athletic trainer failed to perform the task competently.


Respondents were asked to rate the criticality of the 28 tasks and five domains on a 4‐point scale. Average criticality statistics were calculated for each task and domain and ranged from 1.40 to 3.76.

Frequency

Frequency was defined as:

The time that a competent athletic trainer spends performing duties within each domain or task.

Respondents were asked to rate the frequency with which they performed the 28 tasks and five domains on a 4‐point scale. Average frequency statistics were calculated for each task and domain and ranged from 1.69 to 3.68.

Importance

Consistent with the Standards for Educational and Psychological Testing (American Educational Research Association, 1999), an importance weight was calculated for each respondent’s ratings of a task or domain using the following formula:

Importance = (Criticality)2 + Frequency ......... (1)

Formula 1 was designed to create an importance weight that was as straightforward as possible and that highlighted the impact of the consequences of failure to perform. A weight that emphasizes criticality ensures that less critical but frequent tasks do not dominate the test blueprint. The formulation will also provide an easy mechanism for any future survey to assess changes in the test blueprint weighting because it requires administration of only two scales. By emphasizing criticality the importance formulation used also supports the BOC’s mission of protecting the public from harm. Average importance statistics were calculated for each task and domain and ranged from 4.05 to 17.37.

Assessment was also made as to the critical values for the obtained importance weight. A 99% confidence interval (CI) for mean rating was calculated under the

assumption that tasks or domains rated in importance below this range might be inappropriate for inclusion on the test blueprint. Nine of the tasks were weighted at less than the critical value for tasks (9.6 < t99CI < 12.3, df = 27), and Domain 5 was rated below the critical value (7.4 < t99CI < 18.3, df = 4) for domains.ii

Summary

Respondents to the 2009 BOC athletic trainer role delineation/practice analysis survey found the majority of tasks and domains to be appropriate for inclusion on a competency test for entry‐level athletic trainers. In general, the reliability of the responses was very good.

Based on the importance weights, it was recommended that Domain 5 should form no more than 12% of any test and that task 0107 be capped at 2%. This recommendation would enable the BOC to assess an area of performance that was supported by the panel of subject matter experts but was of relatively low importance for the survey respondents.

Conclusion

The 2009 athletic trainer role delineation/practice analysis study used several well established methods to describe and validate the practice of newly certified athletic trainers in North America:

1. A review of existing role delineation/practice analysis material;

2. Subject matter expert knowledge; and 3. A large scale survey.

The representativeness and reliability of the survey instrument was very good. In addition, there was evidence to support the validity of the task and domain statements.

Based on evidence, the findings of this study can be used to evaluate and support an entry‐level athletic trainer competency test.


STUDY PURPOSE

The Board of Certification (BOC) is a not‐for‐profit credentialing body for individuals with education and experience in the practice of athletic training. The BOC has developed a credentialing program for athletic trainers that meets professional standards and is accredited by the Institute for Credentialing Excellence (ICE).

In order to attain the athletic trainer credential, an individual must complete an entry‐level athletic training education program accredited by the Commission on Accreditation of Athletic Training Education (CAATE), be endorsed by a recognized program director of a CAATE accredited education program, have a current certification in emergency cardiac care, and pass the BOC examination.

The BOC examination focuses on those areas of professional practice required for entry‐level athletic trainers that are critical to ensuring that their clients, the athletic trainer themselves, their employer, fellow employees, and the profession are not physically, financially, or emotionally harmed through their actions.

To ensure that the examination meets this goal, the BOC conducts a periodic review of the profession to determine the areas of professional practice critical for an entry‐level practitioner. In October 2008, the BOC began its sixth role delineation/practice analysis study, the results of which define the content of the examination and are reported in this document.

The BOC is committed to maintaining an examination that is a fair, valid, and reliable assessment. As such, the BOC follows well established processes for determining the content of the examination. The BOC worked with Castle Worldwide, Inc., a certification and licensure design, development, and administrative service company, to ensure that the BOC examination met guidelines and standards for a psychometrically sound and legally defensible examination (e.g., Standards for Educational and Psychological Testing, Joint Committee on Standards for Educational and

Psychological Testing, 1999; Uniform Guidelines on Employee Selection Procedures, EEOC, 1978).

Some important definitions

Before venturing in to the complete report there are some important definitions required for understanding of the material presented.

Licensure

Licensure is a government regulated process based on the legal concept that a government entity has the right and obligation to pass laws and take other such actions as it may deem necessary to protect the health, safety, and welfare of its citizens. Passage of a licensure or credentialing law or regulation for a given profession restricts or prohibits the practice of that profession by individuals not meeting qualification standards, and violators may be subject to legal sanctions such as fines, loss of license to practice, or imprisonment

Certification

Certification is a voluntary process designed to establish that a person has met professional standards of education, training, and experience. A certification attests to the fact that the person has met the standards of a credentialing organization and is entitled to make the public aware of his or her professional competence.

Tasks

Tasks are the individual functions, whether mental or physical, required for certain aspects of a job or profession, essentially a description of critical duties performed. Tasks state what to do. The set of tasks must be relevant to the purposes of the assessment.

Task statements should provide a clear, complete picture of what is being done, how it is being done, and why it is being done. A complete task statement will answer four questions:

1. Performs what action? (verb)

2. To whom or what? (object of the verb)

3. To produce what? OR Why is it necessary? (expected output)


4. Using what tools, equipment, work aids, processes?

Domains

Domains are the major areas of responsibilities or activities of a job or profession. They represent the logical groupings of the tasks.

Typical jobs/professions consist of four to eight domains often represented by a two or three word descriptor.

Knowledge and skill statements

Knowledge and/or skills (often referred to as KSAs) are about how to do a task. They include information, actions, or other learnable skills a candidate must possess in order to perform a task. An organized body of factual or procedural information is called knowledge. The proficient physical, verbal, or mental manipulation of data, people, or objects is called skill.

Domains and tasks are mutually exclusive, that is, every task is different and cannot be associated with more than one domain, and the domains are also independent. Knowledge and skill can, however, can be related to different tasks across different domains.

Role delineation/practice analysis study

A role delineation/practice analysis study is one of the methods used to identify and prioritize the critical tasks of a job or profession and the essential competencies an individual should possess to perform the required functions satisfactorily.

For certification purposes, a role delineation/ practice analysis study is used to establish a clearly delineated set of domains, tasks, and associated knowledge and/or skills necessary to carry out the responsibilities of the job to the standards required for certification.

Most standards for the accreditation of certification programs (e.g., American National Standards Institute (ANSI), Buros Institute for Assessment Consultation and Outreach (BAICO), ICE) require a

demonstrable linkage between test specifications and the data collected through a role delineation/practice analysis study.

Validity

Validity refers to evidence that the assessment tool measures that which it is intended to measure. Most examinations focus on content validity, which is demonstrated through two processes. First, the content of the examination must be job related. Second, the examination covers areas where lack of knowledge or skill would result in an inability to perform the job.

Measurement validity is typically the accumulation of evidence that rigorous and logical processes have been used to define, design, and develop the test and individual items.

Reliability

Reliability is the degree of consistency of a set of measurements or a measurement instrument. Reliability is typically whether the same instrument gives, or is likely to give, the same measurement (e.g., test‐retest), or in the case of more subjective instruments, whether two independent assessors give similar scores (inter‐rater reliability). Reliability is affected by both the number of candidates and the number of items. If the items are well constructed, the more items on a test, the more reliable the test is.

Reliability does not imply validity. A reliable measure is measuring something consistently, but the statistics does not tell us what it is measuring.


METHODOLOGY

The methodology used for the development of the content and resulting blueprint for the BOC athletic trainer examination consisted of the use of well established protocols for establishing a content valid examination.

First, a review of the existing role delineation/practice analysis tasks and candidate comments was conducted by BOC item writers, Castle test development staff, and BOC exam development personnel to identify tasks that were problematic.

Second, a panel of subject matter experts (SMEs) was convened to develop a new test outline based on a review of the existing tasks and the results of the preliminary analysis.

Finally, an online validation survey was conducted and the results were used to create the test blueprint.

Descriptions of SME panel processes, survey development, sample selection and data collection procedures are provided, as well as information about assurance of confidentiality, response rates, and the degree to which participants were representative of recently certified athletic trainers.

Review of existing role delineation/practice analysis outline

The existing test content outline developed in the 2004 study consists of 37 tasks in six domains.

A review of candidate comments and discussions with test and exam development personnel identified problems with some of the existing tasks in terms of the ability to write meaningful and valid questions. As a result, a survey was prepared for the then current item writers asking them to rate on a scale of 1 (None) to 4 (A great deal) how difficult they found writing items to the task to be. Tasks with low ratings were less difficult to write to than tasks with high ratings. A total of 15 item writers provided ratings on the 37 tasks.

For each task, an overall item writing difficulty rating was calculated. The ratings ranged from 1.43 to 2.73. The associated 99% Confidence Interval (CI)iii was also calculated. A CI is the estimated range of values that a “true” average lies within. The CI limits were used to identify which tasks were rated as very difficult to write to by the item writers, that is, higher than the upper range for the 99% CI. The 99% CI calculation indicated that tasks with a difficulty rating greater than 2.13 were much more difficult than the majority of the tasks. These tasks were highlighted for particular review during the next steps.

Eight tasks had ratings above the 2.13 (the 99% CI), indicating that the item writers had significant difficulty writing items for these tasks. This included all the tasks for Domain 5 (Organization and Administration). Appendix B contains the task list and the average rating for each task. Table 1 provides summary data for the item writer survey.

Table 1: Summary statistics of ratings of item writing difficulty and resulting confidence intervals for 15 BOC item writers of existing 37 tasks, September 2008.

Statistics

Number of tasks 37

Number of judges 15

Average difficulty ratings 1.89 Standard deviation of

difficulty ratings 0.36

Square of N 3.87

Standard error 0.09

Student's t (df = 2, α = 99) 2.624

Upper range 2.13

Lower range 1.64

Following this review step, material was prepared for the panel of subject matter experts.

Panel of subject matter experts (SMEs)

A panel of 23 subject matter experts was enrolled by BOC staff in consultation with Castle to participate in a role delineation/practice analysis panel. Appendix C presents a list of the panel members and their areas of practice.


The panel was held over three days in October 2008 in Omaha, Nebraska. The aim of the panel was to review and reach a consensus about the knowledge, tasks, and domains of performance required of a candidate for certification.

Panel background information

A series of demographic questions were asked of each panel member and the results summarized for the group.

All panel members lived within the U.S., and the states represented a wide geographic range. Twelve of the panel (52%) were female; 20 of the 23 (87%) reported their ethnicity as white. Four of the panel reported their age as 25 to 30, three as 31 to 35, five as 36 to 40, eight as 41 to 50, two as 51 to 60, and one as 61 or more years.

The panel was relatively experienced in the field. Fifteen of the panel members (65%) had 15 or more years of experience in the field, two reported 3 to 5 years, five reported 6 to 10 years, and one reported 11 to 15 years of experience. Of the 23 panel members, one was retired, one worked multiple part‐time contracts, and all others reported working full time. Ten of the panel members worked with educational institutions, four with state or federal government, and the remainder for corporations. Eighteen of the panel members (78%) reported holding a master’s degree, three had bachelor’s, and two had doctorates. Almost all panel members reported holding other degrees and certificates. The panel demographics are provided in Appendix D.

Initial instructions and definitions for the panel

Before competing the panel work, the panel was introduced the concept of a role delineation/ practice analysis study and provided the workbook contained in Appendix E.

Led by Dr. Stephen Johnson, initial discussions with the panel focused on the variety, the format, and the nature of testing. Attention was drawn to the difference between designing a curriculum to educate athletic trainers and a test blueprint designed to assess the critical skills and knowledge

required of an entry‐level athletic trainer. In particular, the difference in the scope of the two was brought to the attention of the panel. It was highlighted that education curricula have a much broader content and scope than test blueprints and that the BOC test specifications are designed to focus on critical skills and knowledge that are directly related to the safe and competent practice of recently certified athletic trainers.

The panel members discussed the terms used to refer to those under the direct care of athletic trainers in a variety of practice settings. The panel determined that individual(s) and groups would be used to reflect the diversity of terms used about those under the direct care of athletic trainers within a variety of situations. Depending on the organization, an individual or group could be referred to as client, student, patient, athlete, team, customer, member, etc.

The concept of Entry‐Level Athletic Trainer was discussed by the panel in detail. The definition was clarified as:

One who has met eligibility requirements and demonstrated an acceptable level of competence in the provision of athletic training services within identified performance domains, all as defined by the Board of Certification (BOC).

The panel was also informed by Dr. Johnson about the population of potential test takers. In order to attain certification, an individual must complete an entry‐level athletic training education program accredited by the Commission on Accreditation of Athletic Training Education (CAATE) and pass the BOC certification exam. A candidate for certification must also meet the following requirements:

Endorsement of the exam application by the recognized Program Director (PD) of the CAATE accredited education program; and

Proof of current certification in emergency cardiac care (ECC). (Note: ECC certification must be current at the time of initial application and any subsequent exam retake registration.)


Defining the tasks and domains

The panel members were presented with the definition of a task by Dr. Johnson with the examples presented in the workbook. Panel members were trained that the tasks for the athletic trainer test blueprint should be:

Relevant to the role of an entry‐level practitioner in the first three years of practice;

Unique and important to the practice of athletic training; and

Testable in the format used by BOC.iv

The panel then developed one task together to help solidify their individual understanding about how a task is constructed.

Following this process the panel reviewed the descriptions of the current 37 tasks. This was presented in a table similar to that contained in Appendix B. The panel members were only provided the task descriptions, with the eight difficult tasks in italics. The panel members were not provided the difficulty ratings, nor were they provided the domains each task was associated with.

Using small group and whole panel formats, the panel members then modified or eliminated existing tasks or created new tasks that were applicable and important to the role of a newly certified athletic trainer and that were testable in the proscribed format.

From this process, a set of 28 tasks were identified as appropriate to the role of a newly certified athletic trainer. Table 2 provides a list of the tasks.

Table 2: Twenty‐eight tasks identified by subject matter experts for athletic trainers, October 2008.

Task Description

Minimize risk of injury and illness of individuals and groups impacted by or involved in a specific activity through awareness, education, and intervention. Interpret individual and group pre‐participation and other relevant screening information (e.g., verbal, observed, written) in accordance with accepted and applicable guidelines to minimize the risk of injury and illness. Identify and educate individual(s) and groups through appropriate communication methods (e.g., verbal, written) about the appropriate use of personal equipment (e.g., clothing, shoes, protective gear, and braces) by following accepted procedures and guidelines. Maintain physical activity, clinical treatment, and rehabilitation areas by complying with regulatory standards to minimize the risk of injury and illness. Monitor environmental conditions (e.g., weather, surfaces, client work‐setting) using appropriate methods and guidelines to facilitate individual and group safety. Maintain or improve physical conditioning for the individual or group by designing and implementing programs (e.g., strength, flexibility, CV fitness) to minimize the risk of injury and illness. Promote healthy lifestyle behaviors using appropriate education and communication strategies to enhance wellness and minimize the risk of injury and illness. Obtain an individual’s history through observation, interview, and/or review of relevant records to assess current or potential injury, illness, or health‐related condition. Examine by appropriate visual and palpation techniques the involved area(s) of an individual’s body to determine the type and extent of the injury, illness, or health‐related condition. Examine by appropriate and specific tests (e.g., ROM, special tests, neurological tests) the involved area(s) of an individual’s body to determine the type and extent of the injury, illness, or health‐related condition. Formulate a clinical diagnosis by interpreting the signs, symptoms, and predisposing factors of the injury, illness, or health‐related condition to determine the appropriate course of action.


Task Description

Educate the appropriate individual(s) about the clinical evaluation by communicating information about the current or potential injury, illness, or health‐related condition to encourage compliance with recommended care. Coordinate care of individual(s) through appropriate communication (e.g., verbal, written, demonstrative) of assessment findings to pertinent individual(s). Apply the appropriate immediate and emergency care procedures to prevent the exacerbation of non‐life‐threatening and life‐threatening health conditions to reduce the risk factors for morbidity and mortality. Implement appropriate referral strategies, which stabilize and/or prevent exacerbation of the condition(s), to facilitate the timely transfer of care for conditions beyond the scope of practice of the Athletic Trainer. Demonstrate how to implement and direct immediate care strategies (e.g., first aid, Emergency Action Plan) using established communication and administrative practices to provide effective care. Administer therapeutic and conditioning exercise(s) using appropriate techniques and procedures in order to aid recovery and restoration of function. Administer therapeutic modalities (e.g., electromagnetic, manual, mechanical) using appropriate techniques and procedures based on the individual’s phase of recovery to restore functioning. Apply braces, splints, or other assistive devices according to appropriate practices in order to facilitate injury protection to achieve optimal functioning for the individual. Administer treatment for injury, illness, and/or health‐related conditions using appropriate methods to facilitate injury protection, recovery, and/or optimal functioning for individual(s). Reassess the status of injuries, illnesses, and/or conditions using appropriate techniques and documentation strategies to determine appropriate treatment, rehabilitation, and/or reconditioning and to evaluate readiness to return to a desired level of activity. Provide guidance and/or referral to specialist for individual(s) and groups through appropriate communication strategies (e.g., oral and education materials) to restore an individual(s) optimal functioning. Apply basic internal business functions (e.g., business planning, financial operations, staffing) to support individual and organizational growth and development. Apply basic external business functions (e.g., marketing and public relations) to support organizational sustainability, growth, and development. Maintain records and documentation that comply with organizational, association, and regulatory standards to provide quality of care and to enable internal surveillance for program validation and evidence‐based interventions. Demonstrate appropriate planning for coordination of resources (e.g., personnel, equipment, liability, scope of service) in event medical management and emergency action plans. Demonstrate an understanding of statutory and regulatory provisions and professional standards of the practice of Athletic Training in order to provide for the safety and welfare of individual(s) and groups. Develop a support/referral process for interventions to address unhealthy lifestyle behaviors.

Following the development of the 28 tasks, the panel members were instructed that they would define a series of domains associated with these tasks. A domain was defined as a major area of responsibility or duty that makes up the role of an athletic trainer.

To achieve this domain structure, panel members were led through a series of exercises in which small groups initially grouped similar tasks and then discussed their reasons for the grouping with the

whole panel. From this process, a consensus was reached on the appropriate groupings of tasks. The whole panel was then required to develop a description of the resulting domains. The panel identified five performance domains based on their analysis of the critical tasks. During this process the panel members were allowed to modify, eliminate, or create new tasks. The five domains defined by the panel are described in Table 3.


Table 3: Domains identified by subject matter experts for athletic trainers, October 2008.

Domain Domain Description

1 Injury/illness prevention and wellness protection – Educating participants and managing risk for safe performance and function.

2 Clinical evaluation and diagnosis – Implementing standard evaluation techniques and formulating a clinical impression for the determination of a course of action.

3 Immediate and emergency care – Employing standard care procedures and communicating outcomes for efficient and appropriate care of the injured.

4 Treatment and rehabilitation – Reconditioning participants for optimal performance and function.

5 Organizational and professional health and well‐being – Understanding and adhering to approved organizational and professional practices and guidelines to ensure individual and organizational well‐being.

During the development of the 28 core tasks and groupings into domains, the panel members were also asked to note the types of knowledge and skills candidates should posses to safely and competently perform the identified tasks. During the last phase of the panel meeting, these preliminary knowledge and skill statements were further refined.

The panel was informed that the knowledge and skill statements are used primarily by item writers to develop new items and by the candidates to enable self‐assessment of their skills and knowledge.

Since the knowledge and skills required for a task may change over a short period of time, the knowledge

and skill statements are designed to be updated on a periodic basis, typically yearly, as item writing and further work with candidates help refine the understanding of the knowledge and skills necessary for performance of the 28 core tasks. These knowledge and skill statements were presented to BOC staff for their further review, development, and use. The knowledge and skill statements are contained in a separate document.

The panel member’s list of 28 tasks grouped into five domains was then reviewed by BOC and Castle staff to ensure grammatical consistency and the appropriate level of specificity. The staff of both organizations then constructed the outlines of a validation survey.


DEVELOPMENT, RESPONSE RATES, AND REPRESENTATIVENESS OF THE SURVEY RESPONDENTS

Questionnaire design and distribution

BOC contracted with Castle to conduct a validation survey of the domains and tasks. The survey was conducted in March and April 2009. Using the domains and tasks identified by a subject matter expert panel in conjunction with BOC staff, staff at Castle developed an online questionnaire to be completed by BOC members.

The survey consisted of two parts. The first part asked respondents to rate the domains and tasks, in that order. The second part, or demographics section, consisted of a series of questions that asked respondents to provide information about their places of work and working conditions, for example, the type of facility in which they work.

The survey was reviewed and approved by BOC staff, members of the BOC exam development committee, and members of the October expert panel. The survey tool is provided in Appendix F.

BOC staff provided the contact details and other information for 20,342 BOC certified athletic trainers. From this list, athletic trainers who had been certified between three to seven years were extracted. This group represents BOC certified athletic trainers who are likely to be familiar with the requirements and demands for entry‐level athletic trainers. A total of 7,255 BOC certified athletic trainers (36%) met this criterion. Of this group, a randomly selected subset of 5,000 (69%) were identified as the pool of potential respondents.

The 5,000 potential respondents were sent an initial e‐mail requesting that they complete the survey and evaluate, validate, and provide feedback on the previously identified domains and tasks. During the survey period, three follow‐up e‐mails were sent to those who had not responded or who started but not completed the survey. The e‐mails were sent in text format and designed to arrive in e‐mail inboxes on a

Tuesday through Thursday. Appendix G contains examples of the e‐mails used for the survey.

Three additional requests were sent due to e‐mail address errors, for a total of 5,003 requests

Response rates

A total of 1,152 respondents started the survey. This represents an overall response rate of 23%. Surveys conducted by Castle using a similar contact protocol have response rates that range from 15% to 50%, and within the wider community, a 5% to 15% response rate is typical (e.g., De Champlain, Cuddy, & LaDuca, 2007; NCSBN, 2009).

Of the 1,152 respondents who started the survey, not all individuals responded to every question or provided valid responses; therefore, the total number of responses per question varies. For example, the last task statement was rated by a total of 973 respondents, 84% of those who began the survey. Experience with similar surveys show a completion rate typically between 75% and 85%.

Representativeness of sample

During the initial development of the database used for the analysis, the BOC provided information about the potential respondents that was used to both create the sample group and assess how similar the survey respondents were to the overall sample of BOC athletic trainers certified three to seven years.

The respondents to the survey were compared to the survey requests and the original 7,255 BOC certified athletic trainers on three pieces of data contained in the original database: geographic location, years certified, and practice setting.

For geographic location, the U.S. states were divided into six regions, enabling comparison between the proportion of requests sent to each region and the response rate from each. Region 6 consists of U.S. overseas territories such as the Virgin Islands. There were no BOC certified athletic trainers identified in Region 6 at the time for the survey. Figure 1 identifies the five U.S. regions.


Figure 1: Five U.S. regions for respondents, BOC athletic trainer validation survey, March‐April 2009.

1

4 5

2

A l a s k a

H a w a i i

P u ertoR i c o

3

Table 4 provides a breakdown of the number and associated percentages of respondents, individuals sent requests to participate (Requests), and three to seven year BOC certified athletic trainers (Certified) in

each of the five regions. Four BOC certified athletic trainers and one person requested to participate did not have any region information.

Table 4: Number and percentage of respondents, requests, and BOC certified athletic trainers sent to six U.S. regions, BOC athletic trainer validation survey, March‐April 2009.

Certified Requests Respondents

Region N % N % N %

One 569 7.8 388 7.8 92 8

Two 1,942 26.8 1,321 26.4 325 28.3

Three 1,833 25.3 1,276 25.5 296 25.7

Four 1,389 19.2 972 19.4 229 19.9

Five 1,518 20.9 1,045 20.9 210 18.2

Total 7,251 5,002 1,152

A Chi‐square analysis showed no statistical difference for the regional location of BOC certified athletic trainers and those requested to participate in the survey (χ2 = 0.53, df = 4, p = .97). A Chi‐square analysis of the difference in the proportion of requests and responses from each region indicated a small statistical difference (χ2 = 26.37, df = 4, p < .05). Persons in Region 2 responded at a higher rate than expected, and persons in Region 5 responded at a slightly lower rate than expected. Appendix H provides

a breakdown for each of the three groups by U.S. state.

An analysis was conducted to assess whether there was any difference in the number of years certified between the three groups. Table 5 provides the summary statistics for the three groups for the number of years certified.


Table 5: Mean, Standard Error of the Mean, and Standard Deviation of the number of years certified for respondents, requests, and BOC certified athletic trainers, BOC athletic trainer validation survey, March‐April 2009.

Certified Requests Responses

Number of cases 7255 5003 1152 Mean 5.043 5.037 5.040

Std. Error of Mean .0131 .0158 .0330 Std. Deviation 1.1152 1.1159 1.1203

As can be seen from the table, there was no statistical difference in the means of the three groups. This was confirmed by a t‐test for the difference between the average number of years certified for the respondent group compared to the original group (t95 = 0.09, p < .05).

Finally, an analysis was conducted on the representativeness of the practice settings for the survey respondents. The BOC database described 18 practice settings (Clinic / Hospital – AT; Health / Fitness Industry; Industrial / Corporate; Military /

Government / Law Enforcement; Not Currently Practicing; Other; Professional Sports & Performing Arts; Sales / Marketing; Secondary School – AT; Univ / College / JC – AT; Youth Sports; Secondary School – Administrative; Student; Unknown; Multiple settings; Univ / College / JC – Educator; Univ / College / JC – Administrative; and Clinic / Hospital – Administrative). Table 6 provides a breakdown of the number and proportion for each of the practice settings of the three groups, and Figure 2 provides a graphical summary of the proportions of each of the three groups in the 18 practice settings.


Table 6: Number and percentage of respondents, requests, and BOC certified athletic trainers for each of 18 practice settings, BOC athletic trainer validation survey, March‐April 2009.

Certified Requests Responses

N % N % N %

Clinic/Hospital – AT 1244 17.1 862 17.2 144 12.5

Health/Fitness Industry 346 4.8 240 4.8 34 3.0

Industrial/Corporate 143 2.0 98 2.0 18 1.6

Military/Government/Law Enforcement

41 .6 29 .6 5 .4

Not Currently Practicing 233 3.2 146 2.9 26 2.3

Other 945 13.0 662 13.2 91 7.9Professional Sports & Performing Arts

212 2.9 151 3.0 27 2.3

Sales/Marketing 80 1.1 56 1.1 8 .7

Secondary School – AT 2197 30.3 1531 30.6 394 34.2

Univ/College/JC – AT 1555 21.4 1042 20.8 353 30.6

Youth Sports 37 .5 27 .5 7 .6

Secondary School – Administrative

3 .0 3 .1

Univ/College/JC – Educator 45 .6 30 .6 16 1.4Univ/College/JC – Administrative

9 .1 8 .2 3 .3

Clinic/Hospital – Administrative

29 .4 22 .4 5 .4

Student 82 1.1 58 1.2 15 1.3Unknown 37 .5 29 .6 2 .2Multiple settings 17 .2 9 .2 4 .3

Total 7255 100.0 5003 100.0 1152 100.0


Figure 2: Proportion of each of three groups (Certified, Requests, and Respondents) in 18 professional settings, BOC athletic trainer validation survey, March‐April 2009.

0 5 10 15 20 25 30 35 40

Clinic/Hospital ‐ AT

Health/Fitness Industry

Industrial/Corporate

Military/Government/Law Enforcement

Not Currently Practicing

Other

Professional Sports & Performing Arts

Sales/Marketing

Secondary School ‐ AT

Univ/College/JC ‐ AT

Youth Sports

Secondary School ‐ Administrative

Univ/College/JC ‐ Educator

Univ/College/JC ‐ Administrative

Clinic/Hospital ‐ Administrative

Student

Unknown

Multiple settings

Professional Setting

Percentage of Group

Responses

Requests

Certified

A Chi‐square analysis showed no statistical difference for the professional settings of the 7,255 BOC certified athletic trainers and those requested to participate in the survey (χ2 = 5.16, df = 17, p < .05). A Chi‐square analysis of the difference in the proportion of requests and responses for the settings indicated a statistical difference (χ2 = 131.48, df = 17, p < .05). As can be seen in Figure 2, the analysis indicated that the preponderance of this difference was accounted for by less than expected responses from persons in the “Clinical Hospital – AT” and “Other” settings, and a higher than expected response from the “Univ/College/JC – AT,” and “Univ/College/JC – Educator” settings.

In summary, based on information contained in the original database, the 1,522 respondents to the survey were regionally representative of the 7,255 BOC certified athletic trainers certified between three to seven years. The respondents were also certified for the same number of years as the larger group and

were generally representative of the professional settings, with some over and under representation by professional setting.

The response rate of 23% is consistent with surveys using a similar contact protocol conducted by Castle and higher than those experienced in the survey industry. The completion rate of 84% is consistent with other Castle surveys.

Demographics and professional experiences of the survey respondents

This section reports the analysis of the responses to a series of demographic and professional experience questions presented to the survey participants. Questions asked respondents to provide demographic information (e.g., age, gender), their experience as an athletic trainer (e.g., years practicing), and information about their responsibilities et cetera in their professional setting. The survey respondents could


elect to not answer any of the questions. The survey questions can be found in Appendix F.

Data presented in this section also consists of further examination of the information provided in the BOC database provided for the purpose of this study.

Demographics

Of the 1,152 respondents, 1,032 provided information on their gender. Six hundred and six (59%) indicated they were female, and 426 (41%) indicated they were male.

The database provided though BOC included birthdates, which were used to estimate the age of the respondents at the time of the survey. From this data, the median age of the 1,152 respondents was 28.5 and ranged from 24.1 to 58.5. Two of the respondents were aged less than 25, and two were more than 55. Table 7 provides a breakdown of respondent ages into six categories.

Table 7: Number and percentage of respondents, by age group, BOC athletic trainer validation survey, March‐April 2009.

Age Range Number Percent

Under 25 2 0.2%25 to 30 843 81.7%31 to 40 171 16.6%41 to 45 7 0.7%46 to 55 7 0.7%More than 55 2 0.2%

Total 1,032

Data provided by the BOC also included the date that the respondent received his or her BOC certification. This enabled a calculation to be made as to the respondent’s age at certification. The median age of certification was 22.9 and ranged from 20.7 to 54.9. Figures 3 and 4 present graphs of the ages and age of certification of survey respondents.


Figure 3: Histogram of respondent ages at the time of the survey, BOC athletic trainer validation survey, March‐April 2009.

Figure 4: Histogram of respondent ages at the time of the certification, BOC athletic trainer validation survey, March‐April 2009.


Respondents to the survey were asked to indicate their ethnic background in six categories (Table 8).

Table 8: Number and percentage of respondents, by ethnicity, BOC athletic trainer validation survey, March‐April 2009.

Ethnicity Number Percent

African American 32 3.1%Asian American 21 2.1%Caucasian 920 89.9%Hawaiian or Other Pacific Islander

12 1.2%

Hispanic 20 2.0%Multi‐ethnic 17 1.7%Native American or Alaska Native

1 0.1%

Total 1023

Respondents were also asked to indicate the highest level of education that they had currently earned. Table 9 provides a breakdown of the education levels into eight categories.

Table 9: Number and percentage of respondents, by highest level of education earned, BOC athletic trainer validation survey, March‐April 2009.

Education Level Frequency Percent

Bachelor's degree AT major

196 19.2%

Bachelor's degree other major

49 4.8%

Some graduate program 61 6.0%Master's degree AT major

187 18.3%

Master's degree other major

465 45.5%

Other: M.D. 2 0.2%Doctoral degree AT major

3 0.3%

Doctoral degree other major

60 5.9%

Total 1023

Professional experience

The survey respondents were asked to indicate the number of years they had practiced as an athletic trainer in one of five categories (Table 10).

Table 10: Number and percentage of respondents, by years practicing, BOC athletic trainer validation survey, March‐April 2009.

Years Practicing Number Percent

Up to 2 years 62 6.1%3 to 5 years 489 47.9%6 to 10 years 445 43.6%11 to 15 years 20 2.0%15 or more years 5 0.5%

Total 1021

Separate from the number of years in practice as an athletic trainer, survey requests were sent only to those in the BOC database who had been certified between three to seven years. For the 1,152 respondents, the median number of years certified was 4.9. Figure 5 presents the frequency distribution of the number of years certified for the 1,152 respondents.


Figure 5: Graph for 1,152 respondents of the number of years certified at the time of the survey, BOC athletic trainer validation survey, March‐April 2009.

Practice settings

Survey respondents were asked a series of questions about their work as an athletic trainer, which included the type of practice setting, how many persons they supervised, their annual income from athletic training, and the proportion of their time they worked as an athletic trainer.

Figure 6 details the percent of work time the respondents worked as an athletic trainer. The majority (57%) reported that 75% or more of their time was spent working as an athletic trainer; 19% indicated they worked less than 25% of their time as an athletic trainer.

Figure 7 details the number of athletic trainers or health care providers supervised by the respondents. Seventy‐two percent of the respondents reported not supervising anyone, and 25% reported supervising from one to five persons. Twelve respondents (1.2%) reported supervising more than 10 persons.

Figure 8 provides information on the reported annual income from athletic training. Thirty‐eight percent of the respondents reported between $30,000 and $39,999 in income, with the next highest being those who reported income $40,000 to $49,999 (23%).


Figure 6: Graph for 1,152 respondents of the percent of work time spent as an athletic trainer, BOC athletic trainer validation survey, March‐April 2009.

Figure 7: Graph for 1,152 respondents of the number of athletic trainers or other health care professionals supervised, BOC athletic trainer validation survey, March‐April 2009.


Figure 8: Graph for 1,152 respondents of the annual income earned as an athletic trainer, BOC athletic trainer validation survey, March‐April 2009.

As already reported in Table 6, the BOC database contained information on the practice settings of the survey respondents. The survey respondents were also provided with the opportunity to indicate one or more practice settings they operated in. A total of 1,385 responses were recorded.

Figure 9 details the proportion of responses in each of 17 categories. Twenty‐eight percent of the

respondents were practicing as an athletic trainer in a secondary school setting, 23% were practicing as an athletic trainer in a university/college setting, and 16% were practicing in a clinical setting. Of the 5% not currently practicing, 25% reported themselves studying. Others not currently practicing reported being between positions or other contingencies.


Figure 9: Graph for 1,152 respondents of their reported practice settings, BOC athletic trainer validation survey, March‐April 2009.

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%

Enforcement

Arts

Mi l i tary/Government/Law

Sales/Marketing

Secondary School ‐ Adminis trative

Univ/Col lege.JC ‐ Adminstrative

Industria l /Corporate

Cl inic/Hospita l ‐ Adminis trative

Profess ional Sports and Performing Arts

Youth Sports

Cl inica l/Hospi ta l ‐ Other

Hea lth/Fi tness Industry

Not currently practicing

Univ/Col lege.JC ‐ Educator

Cl inic/Hospita l ‐ AT

Univ/Col lege.JC ‐ AT

Secondary School ‐ AT

Percent

Respondents were also asked, besides the BOC certification, which of 10 health care professional credentials they held. Respondents could select one or more categories. Seventy percent of the responses indicated no other health care certification, and 14% reported a CSCS. Table 11 details the number and percent of responses in each of the 10 categories.

Table 11: Number and percentage of respondents by other health care credential held, BOC athletic trainer validation survey, March‐April 2009.

Credential Number Percent

Nurse Practitioner 0 0.0%Occupation Therapy 1 0.1%M.D./D.O 3 0.3%Ortho Tech Pedorthics 11 1.0%Physician Assistant 15 1.4%ACLS 32 3.0%EMT 37 3.5%Physical Therapy 73 6.9%CSCS 144 13.6%None 741 70.1%

Total responses 1,057


Finally, respondents were also asked to report their job title from a list of nine categories. Forty percent of the responses indicated that their title was as “Athletic Trainer,” followed by 31% who reported “Head Athletic Trainer.” Seventeen percent reported other titles. The table below (Table 12) details the number and proportion of responses in each of the categories.

Table 12: Number and percentage of respondents by position title, BOC athletic trainer validation survey, March‐April 2009.

Title Number Percent

Athletic trainer 301 40.0%Head athletic trainer 235 31.3%Not practicing 43 5.7%Educator 37 4.9%

Administrator 5 0.7% Staff athletic trainer 0 0.0%

Physician extender 0 0.0%

Program director 0 0.0%

Total 621


VALIDATION OF TASKS AND DOMAINS

The BOC athletic trainer role delineation/practice analysis survey respondents were asked to evaluate each performance domain and task, rating each on criticality and frequency. From these ratings, an importance weight was constructed in order to create the proposed test blueprint.

Defining the criticality measure

For the respondents to the survey, criticality was defined as:

The degree to which workers, clients, a member of the public, or other stakeholders would be physically, emotionally, or financially harmed if the athletic trainer failed to perform the task competently.

Criticality was rated using the following four‐point scale:

No Harm 1 Inability to perform tasks would lead to error with no consequences.

Some Harm

2 Inability to perform tasks would lead to error with minimal adverse consequences.

Moderate Harm

3 Inability to perform tasks would lead to error with moderate adverse consequences.

A Great Deal of Harm

4 Inability to perform tasks would definitely lead to error with severe consequences.

Survey respondent criticality ratings were scored from 1 to 4, where a response of “No Harm” was scored 1 and a response of “A Great Deal of Harm” was scored 4.

Defining the frequency measure

For the respondents to the survey, frequency was defined as:

The time that a competent athletic trainer spends performing duties within each domain or task.

Frequency was rated using the following four‐point scale:

Never 1 The athletic trainer does not perform this task at all.

Sometimes 2 The athletic trainer sometimes performs this task.

Often 3 The athletic trainer often performs this task.

Always 4 The athletic trainer always performs this task.

Survey respondent frequency ratings were scored from 1 to 4, where a response of “Never” was scored 1 and a response of “Always” was scored 4.

Defining reliability of the measures used

Reliability of the criticality and frequency measures used was also assessed. Reliability is the degree of consistency of a set of measurements or a measurement instrument. Reliability is typically whether the same instrument gives, or is likely to give, the same measurement (e.g., test‐retest), or in the case of more subjective instruments, whether two independent assessors give similar scores (inter‐rater reliability). Both the number of respondents and the number of items affects reliability. Given that the items are well constructed, the more items in an assessment tool (whether test or survey scale), the more reliable the measure is.

Reliability does not imply validity. A reliable measure measures something consistently, but the statistics does not tell us what it is measuring. As a general rule, a reliability of 0.70 or higher is desirable (Nunnally & Bernstein, 1994). The higher the reliability estimate, the more confidence a user can have that the discriminations between responses at different levels on the measure are stable differences. For the measures used in these studies, Cronbach’s alpha (Cronbach, 1951) was estimated.

Criticality and frequency measures for domains

The average rating of criticality for the five domains was 2.97 with a standard deviation of 0.54. The average frequency rating for the five domains was


3.26 with a standard deviation of 0.32 (see Appendices H and I for domain criticality and frequency statistics).

Table 13 summarizes the number and percent of respondents’ ratings of criticality and frequency for the five domains.

Table 13: Number of survey respondents and percentage for criticality and frequency ratings for five domains, BOC athletic trainer validation survey, March‐April 2009.

Domain 01 02 03 04 05

Scale Count % Count % Count % Count % Count %

No Harm 56 5.0 36 3.2 32 2.9 37 3.3 178 15.9

Some Harm 295 26.3 119 10.6 28 2.5 285 25.4 535 47.9

Moderate Harm 557 49.6 560 49.9 148 13.2 652 58.2 318 28.5

A Great Deal 215 19.1 407 36.3 914 81.5 146 13.0 85 7.6

Never 12 1.1 7 0.6 56 5.0 4 0.4 44 3.9

Sometimes 121 10.8 33 2.9 254 22.7 84 7.5 330 29.6

Often 500 44.5 269 24.0 420 37.5 463 41.4 467 41.9

Always 490 43.6 813 72.5 391 34.9 567 50.7 274 24.6

As can be seen in Table 13 (and Appendices H and I), when comparing the ratings for the five domains, Domain 3 was rated most critical but of relatively low frequency. Domain 2 rated second highest in criticality and highest in frequency, with Domain 1 in the middle for both scales. Domain 4 was rated second highest for frequency but fourth for criticality. Domain 5 was rated least critical and frequent of the five domains.

Reliability estimates using Cronbach’s alpha were made for the domain criticality and domain frequency measures with each measure consisting of five items. The average reliability for domain criticality was 0.79 with the five items ranging in correlations from 0.28 to 0.53. The data indicated that ratings of domain criticality were reliable but relatively independent. Reliability for the domain frequency ratings was 0.54 indicating a less consistent measurement tool. Review of the correlations between the ratings indicated they ranged from 0.18 to 0.24. The data indicated that ratings of domain frequency were relatively independent.

Review of the correlations between the ratings of domain criticality and frequency was also undertaken. We would expect that the sets of ratings

would be somewhat independent, that is, that criticality would not highly correlate with frequency. If they are moderately correlated (generally held as a correlation of 0.5 and above; Nunally & Bernstein, 1994), then they are likely to be measuring a similar concept.

Review of the correlation matrix (see Appendix K) showed that the criticality and frequency ratings for the domains were relatively independent, that is, there was little evidence of a strong correlation between criticality and frequency ratings for each domain. The correlations between a domain’s rating of criticality and frequency ranged from 0.00 to 0.33.

In summary, the correlations statistics indicate that domain criticality and frequency are essentially independent measures. While there was consistency in that ratings of criticality across domains by respondents, respondents were less consistent in their ratings of frequency across domains.

Criticality and frequency ratings for tasks

The average criticality for the 28 tasks was 2.69 with a standard deviation of 0.49. The average frequency rating for the 28 tasks was 2.83 with a standard


deviation of 0.53 (see Appendices H and I for task criticality and frequency statistics).

Table 14 summarizes the number and percent of respondents’ for each rating category for criticality and frequency for the 28 tasks.

Table 14: Number and percentage of survey respondents for criticality and frequency ratings for 28 tasks, BOC athletic trainer validation survey, March‐April 2009.

Criticality Frequency

Task

No Harm Some Harm

Moderate Harm

A Great Deal

Never Sometimes Often Always

0101 Count 72 378 480 107 32 312 473 220

% 6.9 36.5 46.3 10.3 3.1 30.1 45.6 21.2

0102 Count 53 254 480 250 100 375 419 143

% 5.1 24.5 46.3 24.1 9.6 36.2 40.4 13.8

0103 Count 58 429 449 100 98 447 362 129

% 5.6 41.4 43.3 9.7 9.5 43.1 34.9 12.5

0104 Count 50 380 478 120 38 222 489 278

% 4.9 37 46.5 11.7 3.7 21.6 47.6 27.1

0105 Count 36 165 465 360 88 297 425 215

% 3.5 16.1 45.3 35.1 8.6 29 41.5 21

0106 Count 74 511 391 48 153 425 322 123

% 7.2 49.9 38.2 4.7 15 41.5 31.5 12

0107 Count 186 611 203 21 178 516 254 71

% 18.2 59.8 19.9 2.1 17.5 50.6 24.9 7

0201 Count 71 212 470 244 19 72 340 566

% 7.1 21.3 47.1 24.5 1.9 7.2 34.1 56.8

0202 Count 57 196 476 268 10 35 272 680

% 5.7 19.7 47.7 26.9 1 3.5 27.3 68.2

0203 Count 35 162 483 317 9 37 271 680

% 3.5 16.2 48.4 31.8 0.9 3.7 27.2 68.2

0204 Count 41 104 474 375 16 49 283 646

% 4.1 10.5 47.7 37.7 1.6 4.9 28.5 65

0205 Count 60 250 501 183 13 67 371 543

% 6 25.2 50.4 18.4 1.3 6.7 37.3 54.6

0301 Count 78 282 454 174 32 173 449 334

% 7.9 28.5 46 17.6 3.2 17.5 45.4 33.8

0302 Count 22 35 104 826 116 314 319 238

% 2.2 3.5 10.5 83.7 11.8 31.8 32.3 24.1

0303 Count 39 106 349 494 98 319 386 184

% 3.9 10.7 35.3 50 9.9 32.3 39.1 18.6

0304 Count 44 88 345 510 154 365 314 153

% 4.5 8.9 35 51.7 15.6 37 31.8 15.5

0401 Count 32 346 506 95 15 110 429 425

% 3.3 35.3 51.7 9.7 1.5 11.2 43.8 43.4

0402 Count 40 294 441 205 55 157 360 408

% 4.1 30 45 20.9 5.6 16 36.7 41.6

0403 Count 47 383 455 95 39 307 398 236

% 4.8 39.1 46.4 9.7 4 31.3 40.6 24.1


Criticality Frequency

Task

No Harm Some Harm

Moderate Harm

A Great Deal

Never Sometimes Often Always

0404 Count 35 232 558 154 15 120 461 383

% 3.6 23.7 57 15.7 1.5 12.3 47.1 39.1

0405 Count 44 237 519 172 10 111 445 406

% 4.5 24.4 53.4 17.7 1 11.4 45.8 41.8

0406 Count 105 394 399 73 41 334 425 171

% 10.8 40.6 41.1 7.5 4.2 34.4 43.8 17.6

0501 Count 523 359 84 9 336 403 189 47

% 53.6 36.8 8.6 0.9 34.5 41.3 19.4 4.8

0502 Count 662 245 62 6 464 375 107 29

% 67.9 25.1 6.4 0.6 47.6 38.5 11 3

0503 Count 226 386 258 105 44 151 377 403

% 23.2 39.6 26.5 10.8 4.5 15.5 38.7 41.3

0504 Count 113 276 352 231 130 413 289 140

% 11.6 28.4 36.2 23.8 13.4 42.5 29.7 14.4

0505 Count 167 356 312 138 136 345 306 186

% 17.2 36.6 32.1 14.2 14 35.5 31.4 19.1

0506 Count 138 375 359 101 348 442 146 37

% 14.2 38.5 36.9 10.4 35.8 45.4 15 3.8

Reliability of criticality and frequency ratings

Reliability estimates using Cronbach’s alpha were made for the criticality and frequency measures with each measure consisting of the tasks associated with their respective domains, that is, all the seven tasks for Domain 1 were assessed for reliability of their criticality and frequency ratings. We would expect that to an extent greater than the domain ratings, if the tasks within each domain were grouped correctly by the panel, then the reliability for each measure would be very high.

This would indicate that the tasks within each domain are similar in nature. We would also expect

that if our measures of criticality and frequency were largely independent, that is, assessing different concepts, then the correlations between the frequency and criticality for the tasks within a domain should be low (generally less than 0.5; Nunally & Bernstein, 1994).

Table 15 provides details in the reliability statistics and number of tasks for each of the 16 measures (five for criticality and five for frequency).


Table 15: Number of survey respondents and tasks, and associated Cronbach’s alpha for criticality and frequency ratings for tasks within five domains, BOC athletic trainer validation survey, March‐April 2009.

Domain Measure Alpha N of People

N of Tasks

1 Criticality 0.85 1018 7

Frequency 0.80 1016 7









As per our expectations, the data indicated that ratings of task criticality and frequency were very reliable, though ratings of task frequency for Domain 5 were slightly less reliable than the other measures. A review of the correlations between the ratings of frequency for the tasks showed relatively low correlations (0.2 to 0.4) compared to 0.4 and above for the other measures.

Review of the correlation matrix (see Appendix L) showed that the criticality and frequency ratings for the tasks were relatively independent, that is, there was little evidence of a strong correlation between criticality and frequency ratings for the tasks within a domain. The correlations between a domain’s rating of criticality and frequency typically ranged from 0.0 to 0.2, with a few correlations around 0.3.

In summary, the correlations statistics indicate that criticality and frequency are essentially independent measures. The measures of criticality and frequency for the tasks within a domain were very reliable, indicating they were assessing similar concepts.

Defining the importance weight

For both criticality and frequency, respondent ratings were scored from one to four, which enabled the development of a metric for weighting the domains and tasks. For each respondent, a third variable, an importance weight (weight), was calculated by squaring each respondent’s criticality and adding his or her rating of frequency.

Weight = (criticality)2 + frequency ........... (1)

Standard practice within the field for test blueprint design is to use weights that are as straightforward as possible and that highlight the impact of the consequences of failure to perform a task. Formula 1 was designed to meet both of these criteria, particularly as the criticality scale has more impact on the final importance weight. By emphasizing criticality, the weight formulation used supports the BOC’s mission of protecting the public from harm. A weight that emphasizes criticality ensures that less critical but frequent tasks do not dominate the final test blueprint. The formulation will also provide an easy mechanism for any future survey to assess changes in the test blueprint weighting because it requires administration of only two scales (criticality and frequency). Table 16 provides a summary of the statistics for the importance weight calculated for each domain and task.


Table 16: Number of survey respondents and average and standard deviation of importance weight for 28 tasks and five domains, BOC athletic trainer validation survey, March‐April 2009.

Number of People

Mean

Std. Deviation

Skewness Kurtosis

Statistic Std. Error Statistic

Std. Error Statistic

Std. Error

Domain 01 1123 11.93 .14 4.65 .34 .07 ‐.64 .15

Domain 02 1122 14.43 .14 4.61 ‐.17 .07 ‐.86 .15

Domain 03 1121 17.37 .11 3.82 ‐2.05 .07 3.64 .15

Domain 04 1118 11.80 .12 4.05 .39 .07 .01 .15

Domain 05 1115 8.73 .13 4.39 .99 .07 .56 .15

0101 1037 10.19 .14 4.37 .59 .08 ‐.08 .15

0102 1037 11.64 .15 4.94 .23 .08 ‐.87 .15

0103 1036 9.66 .13 4.29 .73 .08 .12 .15

0104 1027 10.57 .14 4.38 .62 .08 ‐.12 .15

0105 1025 13.13 .16 5.00 ‐.06 .08 ‐1.08 .15

0106 1023 8.67 .12 3.89 .81 .08 .49 .15

0107 1019 6.92 .11 3.36 1.27 .08 2.16 .15

0201 997 12.54 .15 4.88 .14 .08 ‐.88 .15

0202 997 13.07 .15 4.83 .07 .08 ‐.87 .15

0203 997 13.76 .15 4.74 ‐.04 .08 ‐.94 .15

0204 994 14.36 .15 4.76 ‐.24 .08 ‐.86 .15

0205 994 12.00 .15 4.61 .30 .08 ‐.58 .15

0301 988 11.27 .15 4.65 .34 .08 ‐.62 .16

0302 987 17.19 .12 3.74 ‐2.12 .08 3.91 .16

0303 987 14.32 .15 4.84 ‐.55 .08 ‐.79 .16

0304 986 14.29 .16 4.96 ‐.59 .08 ‐.76 .16

0401 979 10.94 .13 3.98 .55 .08 .09 .16

0402 980 11.78 .15 4.82 .34 .08 ‐.76 .16

0403 980 10.19 .13 4.15 .63 .08 .04 .16

0404 979 11.87 .14 4.26 .37 .08 ‐.20 .16

0405 972 11.94 .14 4.48 .34 .08 ‐.45 .16

0406 971 9.38 .14 4.21 .67 .08 .12 .16

0501 975 4.88 .10 3.06 1.69 .08 3.84 .16

0502 975 4.05 .09 2.74 2.16 .08 6.07 .16

0503 975 9.09 .16 4.85 .87 .08 ‐.02 .16

0504 972 10.77 .17 5.38 .29 .08 ‐1.03 .16

0505 973 9.35 .17 5.19 .68 .08 ‐.44 .16

0506 973 8.53 .15 4.53 .71 .08 ‐.14 .16

Average for task 956 10.90 .54 2.86


Assessment was made as to the critical values for the obtained weights. A 99% confidence interval (CI)v for task weights was calculated under the assumption that tasks with an importance weight of less than the lower value for the 99% CI might be inappropriate for inclusion on the test blueprint, that is, their importance was rated by survey participants as low.

Eight of the tasks were weighted at less than the critical value (9.61 < t99CI < 12.27 df = 27). Of these, three tasks (0107, 0501 and 0502) were rated substantially below this level. One additional task (0103) had a weight of 9.66, a borderline value.

Of the five domains, one domain (Domain 5) was rated below the critical value (7.44 < t99CI < 18.27, df = 4).


DEVELOPMENT OF THE PROPOSED TEST BLUEPRINT

The next step in the blueprint development was to establish the percentage of the test blueprint for each of the tasks and domains.

A role delineation/practice analysis study and its resulting test blueprint are typically in active use for three to seven years. However, over this period, the number of scored items on an examination may change for administration and/or development needs. For example, a test may start with 150 scored items, but as the program matures, scored items may be reduced to 120 and experimental, or unscored, items increased to 30. To maintain validity of the examination, test blueprints are designed to refer to the percentage of scored items, that is, those items that assess the core prerequisite information to perform in the field.

The percentages for each task are computed by comparing the proportion a task’s importance weight has in comparison to the sum of the importance weight for all the tasks. For example, if the sum of all the tasks importance weight was 200 and a task had an individual weight of 20, it would be assigned 10% of the items on a test.

Capping the tasks rated low in importance

The weightings for tasks 0107, 0501, and 0502 from the survey respondents would suggest that these tasks are not currently appropriate for inclusion on the BOC assessment. The ratings for both criticality and frequency for these tasks were also rated below their respective 99% CI values. Review of the panel discussion notes indicated that there was substantial discussion regarding all of these tasks. The importance weight for Domain 5 was also low.

Based on these results, it was recommended that all the tasks for Domain 5 be set to no more than two percent of the test blueprint, and that task 0107 also be set to no more than two percent. As a consequence, Domain 5 with its six tasks would form no more than 12% of any test. This recommendation was accepted by the BOC Board in June of 2009.

This capping of Domain 5 and task 0107 would enable the BOC to assess an area of performance that was vigorously discussed and supported by the panel of subject matter experts, but also reflect the current low importance rating provided by the validation survey respondents.

Calculating the remaining 21 tasks

As noted above, the percentages assigned to the tasks for Domain 5 and task 0107 were all set to 2%. The proportion assigned to the other 21 tasks was calculated based on the need to cover the remaining 86% of the examination [100‐(7*2) = 86]. The importance weight for each task was compared to the sum of the importance ratings for those 21 tasks. From this a percentage of the final examination was recommended.

Flexibility in the proportion assigned to a task

Due to the nature of exam development, exactly matching the percentage of items assigned to individual tasks is neither always possible nor desirable. For example, if a poorly worded item is placed in a test because it enables precise alignment to the test blueprint, this will result in a loss of information and a potential loss in face validity.

There is also measurement error in any tool. The importance weight for each task is actually a result of the “true” importance weight and measurement error. As a consequence, it is likely that the “true” importance weight for any task lies within a range of values.

For these two reasons, the test blueprint was designed to provide some flexibility in the percentage of items assigned to each task. This was achieved by multiplying the Standard Deviation of the task weights by two and converting this number to a percentage.vi This percent was then added and subtracted from the average percent for each task in order to provide a minimum and maximum percentage. The error value across the 28 tasks was approximately +/‐ 2%.

In order to reflect the results of the validation survey, the percent of the test assigned to each domain should meet the average percent as determined by


the domain importance weights provided by the survey respondents. For example, the individual tasks for Domain 5 could range from 0% to 3% of scored items on any individual test form, but 12% of every test form will be composed of items from Domain 5.

The mixture of flexibility in meeting the percentages for individual tasks and the requirement to meet the

percentage for a domain will enable the BOC to meet content coverage but retain flexibility to use the best items for the examination.

Table 17 details the tasks associated with each domain, and proportion of items.

Table 17: Description and proportion of items for the BOC athletic trainer examination.

Description % of Exam

Domain 1 Injury/illness prevention and wellness protection – Educating participants and managing risk for safe performance and function.

25%

Domain 2 Clinical evaluation and diagnosis – Implementing standard evaluation techniques and formulating a clinical impression for the determination of a course of action.

22%

Domain 3 Immediate and emergency care – Employing standard care procedures and communicating outcomes for efficient and appropriate care of the injured.

19%

Domain 4 Treatment and rehabilitation – Reconditioning participants for optimal performance and function.

22%

Domain 5 Organizational and professional health and well‐being – Understanding and adhering to approved organizational and professional practices and guidelines to ensure individual and organizational well‐being.

12%


APPROVAL BY THE BOC

Based on the results of the panel meeting and survey responses, Castle staff recommend that the BOC Board accept a test blueprint that:

Consisted of 28 tasks grouped into 5 performance domains;

Provided a range of minimum and maximum percentages for each task to enable the percent of items to vary from test form to test form based on the quality of the items available;

Provided a required percent for each domain;

Restricted the percentage of scored items in a test form assigned to Domain 5 to be no more than 12% of the examination;

Capped individual tasks within Domain 5 to range from 0 to 3% of a test form; and

Capped task 0107 similar to the tasks within Domain 5 (from 0 to 3% of the examination).

These recommendations were accepted and approved by the BOC Board in June 2009.

The knowledge and skill statements generated by the panel of subject matter experts was presented to BOC staff for further review, development, and use. The knowledge and skill statements are contained in a separate document.

i Confidence Limits = Average ± (SEM*Student’s t CI Multiplier) ii A confidence interval (CI) gives an estimated range of values within which the “true” average lies. A CI 99% establishes that there

is a 99% probability that the true average lies somewhere between an upper and lower boundary. CIs are a widely used statistic and can be found in many different statistical textbooks. The CI methodology used here is for an unknown mean and unknown standard deviation and uses Student’s t distribution. See www.stat.yale.edu/Courses/1997‐98/101/confint.htm for an example of estimating. iii Confidence Limits = Average ± (SEM*Student’s t CI Multiplier) iv The existing BOC examination consists of an examination with two components: a multiple‐choice test with 125 scored and 20 experimental items and a hybrid problem portion. v A confidence interval (CI) gives an estimated range of values within which the “true” average lies. Using CIs allows statements about the probability that the true average is within a certain range. A 99% CI establishes that there is a 99% probability that the true average lies somewhere between an upper and lower boundary. CIs are a widely used statistic and can be found in many different statistical textbooks. The CI methodology used here is for an unknown mean and unknown standard deviation and uses Student’s t distribution. See http://www.stat.yale.edu/Courses/1997‐98/101/confint.htm for an example of estimating. vi The use of this multiplier implies that by Chebyshev's inequality, 75% of the weight values lie within this range.


REFERENCES

Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16, p. 297‐334.

De Champlain, A.F., Cuddy, M.M., & LaDuca, T. (2007). Examining Contextual Effects in a Job Analysis: An Application of Dual Scaling. Educational Measurement: Issues and Practice, 26(3), p. 3‐11.

Equal Employment Opportunity Commission (EEOC), U.S. Civil Service Commission, U.S. Department of Labor, and U.S. Department of Justice. (1978). Uniform Guidelines on Employee Selection Procedures. Federal Register, 43 (166), p. 38290‐38315.

Joint Committee on Standards for Educational and Psychological Testing (American Educational Research Association, American Psychological Association, National Council on Measurement in Education) (1999). Standards for Educational and Psychological Testing. Washington, D.C.: AERA.

National Council of State Boards of Nursing (NCSBN). (2009). The 2008 RN Practice Analysis: Linking the NCLEX‐RN® Examination to Practice. (Research Brief Vol. 36). Chicago: Anne Wendt.

Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric Theory (3rd ed.). New York: McGraw‐Hill.


APPENDICES

Appendix A: Classification system of domains, tasks, and knowledge and skill statements

Performance Domain 1: Prevention

Injury prevention is an important responsibility of the athletic trainer (AT). As health care professionals, ATs are often responsible for keeping the active patient active. Active individuals require adequate nutrition1‐4 and fluid replacement5,6 as a first‐line means of preventing many injuries and illnesses. In some instances, active individuals may require additional care to prevent injury and illness during physical activity. These individuals may suffer from systemic disorders like sickle cell trait or anemia7, diabetes8‐13, asthma14‐16or other conditions which do not prohibit participation, yet pose additional prevention concerns.17 Active individuals often exhibit wide variations in body weight and composition, which may influence the relative risk of physical activity.18‐20 Still other participants may report for activity out of shape and their fitness level must be assessed and addressed21‐24.

One step in minimizing the risks of participation is through a pre‐participation physical examination (PPE)25,26. The PPE can help identify problems that are not reported by the patient nor are easily observed. Some activities have a higher risk of specific injuries and illnesses that should be fully examined during the PPE by appropriate health care professionals.

Once the individual is cleared for participation, the AT must attempt to minimize risks during performance. Environmental conditions27, and outdoor hazards28 must be considered. Careful attention should be given to exercise in a hot environment6,29,30,32 and the AT should understand how to prevent and recognize heat illness as well as injury due to cold environments.36‐38

Bracing, taping, and padding are prevention strategies that may be used by the AT.39‐41 ATs may also be able to prevent disease transmission by complying with current standards for blood borne pathogens42‐46, Methicillin‐Resistant Staphylococcus Aureus (MRSA)47, infectious diseases48‐50 and other indoor or outdoor hazards28.

Active patients often have such a desire to succeed that they turn to performance enhancing drugs33,51‐63 , alcohol64,65 and nutritional supplements35. The AT must be knowledgeable on the physiological and psychological effects of the current performance‐ and image‐enhancing products on the market.

The AT must take special care to prepare for situations that arise during participation. General emergency preparation66‐68 is essential, as is knowledge of first aid69‐71. ATs must be current with their knowledge and skill for treating contusions, fractures, abrasions and orthopedic injuries.

The attention to life threatening problems plays a part in all ATs’ preparedness, and those problems include cardiac emergencies31,72‐78, brain injuries79, and other catastrophic injuries80‐85.

Minimize risk of injury and illness of individuals and groups impacted by or involved in a specific activity through awareness, education, and intervention.

Physical activity carries an inherent risk of injury or illness. Some activities have a higher risk of injury as documented in epidemiological studies86,87. Behavioral risks are more common in certain activities and must be recognized. Concerns over weight loss and body image are more common in wrestling, gymnastics and bodybuilding.88,89 While proper nutrition may be used to improve performance, inadequate nutrition, disordered eating,89,91,92 and incorrect methods for weight loss are associated with heightened risk of injury and illness.18 Nutritional considerations are also critically important for participants with chronic medical conditions, such as diabetes or anemia. Performance‐ and image‐enhancing drugs are a continuing concern for both participants and health care professionals involved in physical activity.33,55 Many active individuals are drawn to the positive effects of these drugs and attempt to escape the rules and controls imposed to keep the playing field level. In the area of endurance, performance enhancement often focuses on blood doping as a means to increase the bloods’ ability to carry oxygen.54,62,63 The AT must also be aware of the effects of social drugs and alcohol


and be able to counsel patients on the consequences of each substance.93

Fitness and conditioning are an important part of preparing for safe participation in physical activities. Fitness assessment should be undertaken prior to prescribing an exercise program.21,23,86,94 Special attention must be given to adult and mature populations to help them establish and maintain a personal fitness program.20,95‐98 Fitness can also be a means for weight loss and avoidance of weight gain in the population being served.18,19

The AT must be cognizant of universal precautions and workplace safety.42,43,99 ATs must be aware of the precautions to use when working with patients with HIV as well as knowing what to do in the case of exposure to body fluid.100‐102

Certain sports and activities place participants at higher risk of injury. Often, these sports involve collisions between participants, or between participants and objects.82 Preventing head or neck injuries is essential for the AT, as is the knowledge of how to manage a potential brain79 or spine injury.80,83,103,104 A well established emergency plan is critical for every AT working with active individuals.66,105

The AT must be knowledgeable of medical conditions that put the active individual at risk. Asthma14,15 and diabetes12,13 are two of the more common conditions, but other medical and orthopedic conditions pose additional risks to the participant. Cardiac abnormalities have become more common in the active population, causing the AT to be aware of cardiac risks106,107 and screening procedures.25,108,109 Knowledge of the emergency action plan75,110 and monitoring its effectiveness73 should be a part of every athletic program as is the availability and use of the Automatic External Defibrillator (AED).72,73,111‐114 Each AT should be familiar with the occurrence of sudden cardiac arrest in the population with which they work.31,74,78

Environmental risks may seem to be a regional concern, yet with travel to other locations, understanding all risks becomes important. The AT should always survey the activity area and clear the area of any hazards.28 Weather risks such as extreme

environmental temperatures29,37,86,115,116 and weather disturbances like lightening27 hurricanes, and tornados, and regional conditions such as altitude must be understood.28,86

Prevention takes on all aspects of sports health care and should be the focus of every AT. Constructing a thorough pre‐participation physical examination is usually the first step in identifying potential risks to participation.26,34,86,117 Biomechanical analysis and subsequent adjustment of specific techniques and skills of the sport is helpful in preventing acute and chronic injuries. Sport specific rulebooks assist the AT in understanding preventative measures for a particular sport.115 The AT must use good reasoning and problem solving skills to uncover the myriad of resources available to help prevent the conditions identified in the paragraphs above.

Interpret individual and group pre‐participation and other relevant screening information (e.g., verbal, observed, written) in accordance with accepted and applicable guidelines to minimize the risk of injury and illness.

The AT should be familiar with the pre‐participation examination (PPE) from the design, implementation and analysis.25,26 The AT should contact the state medical association for any published recommendations for sports PPE that differ from national recommendations.26 ATs must periodically review specific screening guidelines published on cardiac evaluation and other medical and orthopedic conditions.25,31,110,116 A review of the HIPAA act of 1996 should help the AT understand the privacy laws to obey.117

Identify and educate individual(s) and groups through appropriate communication methods (e.g., verbal, written) about the appropriate use of personal equipment (e.g. clothing, shoes, protective gear and braces) by following accepted procedures and guidelines.

The AT must be aware of activity‐specific equipment regulations and be able to present that information to the athlete, administration and team.86,115 Periodic weekly and yearly evaluation and reconditioning of equipment should be performed.86 Customization of protective equipment should be understood from the


choice of materials86 to fabrication to the legal ramifications of making protective devices or altering manufactured equipment.86 Proper fitting and fabrication of equipment or custom‐made devices often falls to the AT and thus, should be understood.118,119

With the wide variety of materials, devices and applications, it becomes imperative for the AT to both understand and be able to convey that understanding to the active individual and any other individuals concerned with their safety.120

Maintain physical activity, clinical treatment and rehabilitation areas by complying with regulatory standards to minimize the risk of injury and illness.

The AT must research and follow any institutional, local, state and national (OSHA) safety and sanitation regulations in the activity venue and treatment areas.99,121,122 The AT should follow manufacturer guidelines for maintaining equipment used in the treatment and rehabilitation areas to prolong the life of the equipment and to prevent injury from use. The AT must also understand the health‐related conditions that pose risks within the treatment and rehabilitation areas86,99,123‐126.

The AT must be aware of the operation of modalities, rehabilitation equipment and other non‐expendable equipment used in the treatment facility to insure its proper function and to be able to detect malfunction or disrepair.127,128

Monitor environmental conditions (e.g., weather, surfaces, client work‐setting) using appropriate methods and guidelines to facilitate individual and group safety.

The AT must be aware of the participant’s health history and medical conditions that may predispose them to illness and injury due to environmental conditions.7,11,14,84 Knowledge and recognition of environmental extremes and conditions are important for any location, but also one must be knowledgeable of situations encountered in travel.27,28,86,129‐131 Should an environmental condition exist or develop, the AT must know how to use the available emergency communication systems.72,86 The AT should be aware of published guidelines and position statements

regarding health and safety hazards in sport and exercise and follow those guidelines to prevent or care for environmentally caused illness and injury.5,27,29,36‐38,49,84,116,134,135 Attention must be paid to proper monitoring of environmental conditions and the human responses to exercise in adverse environmental conditions.30,32,84,86,132 When computer access is available, general weather conditions can be checked quite easily130 but should only be used for general information and not specific conditions at each location.

Understanding the proper biomechanics of tasks and movement patterns will aid the AT in ergonomic design to recognize problematic environments to prevent injury and repetitive stress disorders.133 Attention must be paid to the body structure of the participant that may predispose them to ergonomic stresses and potential injury. Student‐athletes and active patients who work are often subject to ergonomic challenges in their activities away from sport (repetitive stress syndromes from poor posture, small computer keyboards, and cell phone keyboards). Understanding how those stresses translate to increased injury is important.133

Safety compromises can occur from surfaces, surrounding equipment, obstacles, equipment or even low light conditions. The AT should be aware of common hazards and be able to inspect the area to recognize potential problems and take steps to reduce the potential for injury.28,86

Maintain or improve physical conditioning for the individual or group by designing and implementing programs (e.g., strength, flexibility, CV fitness) to minimize the risk of injury and illness.

The AT has an important role in the physical conditioning of the participant and must be familiar with the components of a conditioning program.23,86,134 ATs must be current in the understanding of conditioning techniques to be able to converse with the participant and other professionals on the best practice for achieving goals.86,97,134 Understanding the techniques of lifting and conditioning tasks is important in injury prevention.134 Understanding human physiology and the responses to exercise provides a firm foundation


for building conditioning programs and understanding physiological adaptation to exercise.135

Before designing conditioning programs, it is important to understand various techniques and methods to understand proper intervals and stages while addressing the components of a comprehensive conditioning program.86,134

The AT should observe the patient during their conditioning program to be able to correct or modify potentially unsafe or harmful techniques or exercises and be able to instruct the patient in the appropriate use of conditioning equipment.134

The AT must be able to educate the participant, coaches and other interested individuals about the effective use of the conditioning program.134

The AT must follow current recommendations based upon evidenced‐based practice136‐139, when developing conditioning programs appropriate for various populations20,140‐143.

Promote healthy lifestyle behaviors using appropriate education and communication strategies to enhance wellness and minimize the risk of injury and illness.

The AT must be familiar with sound nutritional practices and the guidelines for exercise prescription to best assist the participant.2,86,134 Being able to provide resources and effectively convey that knowledge to the participant, coaches and other personnel is essential.

There must be an understanding of predisposing factors that create or exacerbate nutritional and stress‐related disorders.2,3,135 Knowing how to refer the patient for help and having resources readily available for the patient will assist in the comfortable and nonthreatening transition to wellness.93 Psychological and nutritional difficulties will often be directed to the AT, and thus one must understand the issues such as overtraining, anger management, and stress management and have professional resources available.135

ID Description

Domain 1 Injury/illness prevention and wellness protection – Educating participants and managing risk for safe performance and function.

0101 Minimize risk of injury and illness of individuals and groups impacted by or involved in a specific activity through awareness, education, and intervention.

Knowledge of

Roles of appropriate individuals (e.g., administrators, management, parents/guardians/family members, coaches, participants, and members of the health care team)in risk and illness prevention

Behavioral risks (e.g., nutritional, sexual, substance abuse, blood‐borne pathogens, sedentary lifestyle, and overtraining)

Catastrophic risks (e.g., cardiorespiratory, neurological, thermoregulatory, endocrinological, and immunological)

Common risks (e.g., musculoskeletal, integumentary, neurological, respiratory, and medical)

Effective communication techniques (e.g., multimedia videos, pamphlets, posters, models, handouts, and oral communication)

Environmental risks (e.g. heat, cold, altitude, sunburn, insects, visibility/lighting, and lightning)

Mechanisms of common and catastrophic injury

Preventive measures (e.g., safety rules, accepted biomechanical techniques, ergonomics, and nutritional guidelines)

Skill in Communicating effectively

Identifying appropriate resources Identifying risks

0102 Interpret individual and group pre‐participation and other relevant screening information (e.g., verbal, observed, written) in accordance with accepted and applicable guidelines to minimize the risk of injury and illness.


ID Description

Knowledge of

Established laws, regulations, and policies (e.g., institutional, state, and national) Established guidelines for recommended participation

Pre‐participation evaluation process and procedures Privacy laws

Skill in

Applying appropriate pre‐participation screening information

Applying established guidelines and regulations Collecting appropriate pre‐participation screening information

Identifying appropriate resources Identifying health‐related conditions that may limit or compromise participation

Identifying established guidelines and regulations

0103 Identify and educate individual(s) and groups through appropriate communication methods (e.g., verbal, written) about the appropriate use of personal protective equipment (e.g., clothing, shoes, protective gear, and braces) by following accepted procedures and guidelines.

Knowledge of

Commercially available protective products


Effective use of prophylactic/protective measures

Established standards pertaining to protective equipment (e.g., NOCSAE and ASTM)

Intended purpose, limitations, and capabilities of protective equipment

Legal risks and ramifications of making equipment modifications

Legal and safety risks involved in the construction and use of custom and commercial protective devices

Manufacturer’s guidelines regarding selection, fit, inspection, and maintenance of equipment

Materials and methods for fabricating custom‐made protective devices

Physical properties of the protective equipment materials (e.g., absorption, dissipation, and transmission of energy)

Skill in

Educating individuals on the selection of standard protective equipment

Fabricating and fitting custom‐made devices

Fitting standard protective equipment

Interpreting rules regarding protective equipment

Identifying injuries, illnesses, and health‐related conditions that warrant the application of custom‐made or commercially available devices

Selecting and applying commercial devices

0104 Maintain physical activity, clinical treatment, and rehabilitation areas by complying with regulatory standards to minimize the risk of injury and illness.

Knowledge of Laws, regulations, and policies (e.g., institutional, state, and national) regarding safety and sanitation Manufacturer’s guidelines for maintaining equipment and devices

Health‐related conditions that pose risk

Skill in

Complying with manufacturer’s recommendations for maintenance of equipment

Maintaining a safe and sanitary environment in compliance with established standards (e.g., OSHA, universal precautions, local health department, and institutional policy)

Recognizing noncompliance with safety and sanitation standards

Recognizing malfunction or disrepair of therapeutic modalities, rehabilitation equipment, or furnishings in clinical and treatment areas

0105 Monitor environmental conditions (e.g., weather, surfaces, client work‐setting) using appropriate methods and guidelines to facilitate individual and group safety.


ID Description

Knowledge of

Health‐related conditions of participants that predispose them to environmentally caused illness (e.g., prior heat illness, sickle cell trait, asthma, recent viral infection, use of medication, ergogenic aids, obesity, and dehydration)

Emergency communication systems

Environmental conditions that create risk (e.g., heat, humidity, cold, altitude, pollution, weather extremes, insect swarms, infectious pathogens, and ergonomic conditions)

Ergonomic and epidemiological risk factors as they related to participation

Established standards regarding environmental risks (e.g., governing body rules/regulations, NATA, NCAA, ACSM, etc.)

Hazards common in activity areas (e.g., surface irregularities, obstructions, inadequate offsets, moisture and other foreign objectives, inadequate lighting, inadequate ingress and egress)

Hazards common to equipment (e.g., shoulder pads, goal posts, computer keyboards, desk chairs, hand trucks)

Methods for reducing risk from environmental conditions (e.g., activity scheduling, clothing selection, and fluid replacement)

Policies and procedures for removing participants from environmental risk situations (e.g., heat index, lightning and activity scheduling)

Policy statements and guidelines pertaining to safety hazards (e.g., NATA and NCAA)

Rules governing play and established standards and practices

Skill in

Conducting inspections and recognizing hazards Monitoring techniques (e.g., weight charts, fluid intake, and body composition)

Recognizing environmental and ergonomic risks

Recognizing characteristics in participants that would predispose them to environmental and ergonomic risks

Recommending and implementing appropriate methods for addressing hazards

Using available resources to gather/interpret information regarding environmental data

0106 Maintain or improve physical conditioning for the individual or group by designing and implementing programs (e.g., strength, flexibility, CV fitness) to minimize the risk of injury and illness.

Knowledge of

Components of a physical conditioning program

Current strength and conditioning techniques Ergonomics

Human physiology

Physiological adaptation to exercise (e.g., space and altitude) Various conditioning stages and program intervals

Skill in

Addressing the components of a comprehensive conditioning program (e.g., strength, flexibility, endurance, sport requirements, and individual needs)

Assessing appropriateness of individual or group participation in conditioning programs

Correcting or modifying inappropriate, unsafe, or dangerous activities undertaken in conjunction with physical conditioning programs

Educating appropriate individuals in the effective application of conditioning programs (e.g., guardian, coaches, participants, and administration)

Instructing in the use of appropriate conditioning equipment (e.g., bikes, weight machines, and treadmills)

0107 Promote healthy lifestyle behaviors using appropriate education and communication strategies to enhance wellness and minimize the risk of injury and illness.

Knowledge of

Accepted guidelines for exercise prescription Accepted nutritional practices Effective communication techniques (e.g., multimedia videos, pamphlets, posters, models, handouts, and oral communication)

Predisposing factors for nutritional and stress‐related disorders Professional resources for addictions (e.g., tobacco, alcohol, and narcotics) Professional resources for stress management and behavior modification (e.g., anger management, HIV/STD prevention, and operational stress control)

Related nutritional disorders, inactivity‐related diseases, overtraining issues, and stress‐related disorders


ID Description

Skill in

Accessing information concerning accepted guidelines for nutritional practices

Addressing the issue of special nutritional needs in regard to competition or activity (e.g., pre‐ and post‐game meals and nutritional supplements)

Communicating with appropriate professionals regarding referral and treatment for individuals

Educating appropriate individuals on nutritional disorders, maladaptation, substance abuse, and overtraining

Recognizing signs and symptoms of nutritional, addiction, and stress‐related disorders

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Performance Domain 2: Clinical Evaluation and Diagnosis

Following standardized clinical practices in the area of clinical evaluation and diagnosis, the athletic trainer (AT) is competent to conduct evaluations to determine an injury diagnosis.1‐3 The evaluation is conducted by utilizing a systematic approach throughout the process. One of the most commonly used systems among ATs and other health care providers is the History, Observation/Inspection, Palpation, and Special Tests (HOPS) format. This system helps determine the extent, severity, and nature of the injury/illness leading to a clinical diagnosis.1‐7 The history portion of the examination is subjective in nature while the remaining three areas‐ observation, palpation and special tests are objective findings gathered by the AT throughout the evaluation process.3

The literature describes four distinct evaluation areas the AT maybe asked to perform:

1) The pre‐participation examination which assists in determining the readiness of an individual to participate in physical activities, 2) an on‐field evaluation for acute conditions that had occurred during activity using the primary survey and secondary survey models, 3) a clinical evaluation that often occurs in an off‐field, clinical, or AT healthcare facility setting, and 4) the ongoing evaluation of progress of an injury or illness assisting the AT in advancing or modifying current care and return to activity decisions.2,8

Through the use of an evidence based sequential evaluation process and with the understanding of

injury pathology, the AT provides a clinical diagnosis, determine appropriate immediate care, and establishes and conveys short and long term goals for the affected individual.1‐3,5,8

Obtain an individual’s history through observation, interview, and/or review of relevant records to assess current or potential injury, illness, or health‐related condition.

The evaluation process begins for the AT by conducting an accurate and thorough history. This portion of the evaluation process can set the tone and structure for the remaining exam.4

The AT should ask open‐ended questions to investigate and obtain information. Several authors indicate the history may include: chief complaint of the patient, mechanism of the injury, illness, or condition, nature of the injury or illness, previous and current signs and symptoms, the onset and duration, and type, location, quality, and changes of pain patterns.1‐7,9,10

ATs are one of many health care providers involved with their patients’ health concerns. Because of this, they need to be aware of not only the orthopedic conditions that are frequently encountered, but other general medical conditions.6,9,10 Additionally, the AT should explore any past or present medical history that may be pertinent to the current injury, illness, or condition during the history taking portion of the evaluation.1‐4,7

Utilize appropriate visual and palpation techniques to determine the type and extent of the injury, illness, or health‐related condition.


Inspection and observation begins the objective portion of the evaluation process and assist in determining the severity and nature of the injury.1,3,7 The AT will look for a variety of atypical or unique findings which can include: swelling, gait abnormalities, deformity, discoloration, structural anomalies, atrophy, asymmetry, and skin irregularities.1‐7,9,10

Palpation skills require the AT to have an extensive knowledge of the anatomical structures surrounding the area in question. Through the use of this technique, the examiner can detect tissue damage or changes by comparing the finding of one body part with those of the uninvolved side.4,11 The AT can palpate bony and soft tissues structures for the following: defects, point tenderness, temperature changes, deformities, and symmetry.1‐4,7,11

Utilize appropriate tests (e.g., ROM, special tests, neurological tests) to determine the type and extent of the injury, illness, or health‐related condition.

Special tests have been designed to detect specific pathologies and are often used to confirm what has been learned from the previous portions of the evaluation process.2‐5

Furthermore, the AT should also possess the skill and knowledge to use assorted instruments commonly seen in health care such as sphygmomanometer, vision chart, otoscope and handheld dynamometer.2,5,12,13

Some of the more common special tests noted in the literature include examination of: range of motion, strength, tests to determine integrity of various joints, neurological status, cardiovascular and respiratory status, and functional tests when appropriate.1‐7,9,10

Formulate a clinical diagnosis by interpreting the signs, symptoms, and predisposing factors of the

injury, illness, or health‐related condition to determine the appropriate course of action.

After the AT has concluded the history, observation/inspection, palpation and special tests portions of the evaluation, interpretation of the findings and planning a course of action is necessary. Should a primary survey be implemented, this course will often involve emergency management and providing skills and techniques to reduce or eliminate life threatening conditions.1‐3,7,14

The AT needs to employ problem solving strategies considering differential diagnosis to lead them to an accurate diagnosis.1‐3,7

Educate the appropriate individual(s) about the clinical evaluation by communicating information about the current or potential injury, illness, or health‐related condition to encourage compliance with recommended care.

With an understanding of evidenced based practice, the AT communicates with those involved individuals and health care providers the relevant findings keeping the welfare of the patient in mind.1,3 Along with knowledge of medical terminology and nomenclature, the AT should utilize proper documentation system, often the SOAP (subjective‐objective‐assessment‐plan) format, to develop a written account of the injury, illness, or condition.1‐4,7,15,16

The AT must adhere to Federal, State, and any local privacy acts including Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA).2 Should the patient be a minor, the AT must communicate and educate the patient and family concerning the evaluation, diagnosis, and treatment.2


ID Description

Domain 2 Clinical evaluation and diagnosis – Implementing standard evaluation techniques and formulating a clinical impression for the determination of a course of action.

0201 Obtain an individual’s history through observation, interview, and/or review of relevant records to assess injury, illness, or health‐related condition.

Knowledge of

Biomechanical factors associated with specific activities

Communication techniques in order to elicit information

Injuries, illnesses, and health‐related conditions associated with specific activities Medical records as a source of information

Pathomechanics of injury

Pathophysiology of illnesses and health‐related conditions Relationships between injuries, illnesses, and health‐related conditions and outside factors (e.g., predisposing, nutritional, ergogenic aids, infectious agents, and medications)

Signs and symptoms of injuries, illnesses, and health‐related conditions

Standard medical nomenclature and terminology

The body’s immediate and delayed physiological response to injuries, illnesses, and health‐related conditions

Skill in

Obtaining and recording information related to injuries, illnesses, and health‐related conditions

Identifying anatomical structures involved in injuries, illnesses, and health‐related conditions

Identifying nutritional factors related to injuries, illnesses, and health‐related conditions Identifying psychosocial factors associated with injuries, illnesses, and health‐related conditions Identifying the extent and severity of injuries, illnesses, and health‐related conditions Identifying the impact of supplements and prescription and nonprescription medications associated with injuries, illnesses, and health‐related conditions

Interpreting medical records and related reports

Recognizing predisposing factors to specific injuries, illnesses, and health‐related conditions Relating signs and symptoms to specific injuries, illnesses, and health‐related conditions

0202 Utilize appropriate visual and palpation techniques to determine the type and extent of the injury, illness, or health‐related condition.

Knowledge of

Human anatomy with emphasis on bony landmarks and soft tissue structures

Immediate and delayed physiological response to injuries, illnesses, and health‐related conditions

Normal and abnormal structural relationships to the pathomechanics of injuries and health‐related conditions

Principles of palpation techniques and visual inspection Response to injuries, illnesses, and health‐related conditions Signs of injuries, illnesses, and health‐related conditions Standard medical nomenclature and terminology

Skill in

Assessing immediate and delayed physiological responses to injuries, illnesses, and health‐related conditions

Assessing pre‐existing structural abnormalities and relating them to pathomechanics of injuries, illnesses, and health‐related conditions

Identifying bony surface landmarks and soft tissue abnormalities of specific/ injuries, illnesses, and health‐related conditions

Identifying the relationship and severity of pathological signs of injuries, illnesses, and health‐related conditions

Locating and palpating bony landmarks, articulations, ligamentous structures, musculotendinous units, and other soft tissues

Palpating appropriate structures in order to assess the integrity of human anatomical/physiological systems

Recognizing severity of pathological signs and symptoms of injuries, illnesses, and health‐related conditions

0203 Utilize appropriate tests (e.g., ROM, special tests, neurological tests) to determine the type and extent of the injury, illness, or health‐related condition.


ID Description

Knowledge of

Mechanics, principles, and techniques of specific/special tests (ligamentous, neurological, manual, fracture, and functional tests)

Signs and symptoms of systemic failure during exercise

Signs, symptoms, and interpretations of specific/special tests.

Standard/individual special tests for range of motion, muscular strength, structural integrity, and functional capacity

Skill in

Assessing muscular strength through the use of manual or non‐manual muscle tests

Assessing neurological function Assessing joint range of motion using test and measurement techniques

Identifying appropriate specific/special tests Identifying location, type, function, and action of each joint Identifying structural and functional integrity of anatomical structures

Interpreting the information gained from specific/special tests

Performing specific/special tests

Using equipment associated with specific/special tests

0204 Formulate a clinical diagnosis by interpreting the signs, symptoms, and predisposing factors of the injury, illness, or health‐related condition to determine the appropriate course of action.

Knowledge of

Basic pharmacology associated with diagnosis and courses of action

Signs, symptoms, and predisposing factors related to injuries, illnesses, and health‐related conditions

Guidelines for return to participation Indications for referral Standard medical terminology and nomenclature

Pathomechanics of injuries and/or health‐related conditions

Psychosocial dysfunction and implications associated with injuries, illnesses, and health‐related conditions

Skill in Identifying appropriate courses of action (e.g., treatment plan, referral)

Interpreting the pertinent information from the evaluation

Synthesizing applicable information from an evaluation

0205 Educate the appropriate individual(s) about the clinical evaluation by communicating information about the injury, illness, or health‐related condition to encourage compliance with recommended care.

Knowledge of

Commonly accepted practices regarding the care and treatment of injuries, illnesses, and health‐related conditions


Patient confidentiality rules and regulations Potential health‐related complications and expected outcomes

Role and scope of practice of various health care professionals Standard medical terminology and nomenclature

Skill in


Directing a referral to the appropriate professionals Interpreting standard medical terminology and nomenclature and describing the nature of injuries, illnesses, and health‐related conditions in basic terms

Utilizing appropriate counseling techniques Using standard medical terminology and nomenclature

References




3. Shultz SJ, Houglum PA, Perrin DH. Examination of Musculoskeletal Injuries. 3rd ed. Champaign, IL: Human Kinetics; 2009.

4. Starkey C, Brown S, Ryan JL. Examination of Orthopedic & Athletic Injuries. 2nd ed: FA Davis; 2010.

5. Cummings N, Stamley‐Green, S. Higgs P. Perspectives in Athletic Training. First ed: Elsevier Mosby; 2008.

6. Loudon JK, Swift M, Bell S. The Clinical Orthopedic Assessment Guide. 2nd ed. Champaign, IL: Human Kinetics; 2008.

7. Pfeiffer RP, Mangus BC. Concepts of Athletic Training. 5th ed. Sudbury, MA: Jones and Bartlett; 2008.

8. Starkey C, Brown S, Ryan JL. Orthopedic and Athletic Injury Evaluation Handbook. Philadelphia: F.A. Davis; 2010.

9. Child Z. Basic Orthopedic Exams. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2007.

10. Magee DJ. Orthopedic Physical Assessment. 5th ed. St. Louis, MO: Saunders Elsevier; 2008.

11. Chaitow L. Palpation and Assessment Skills : Assessment and Diagnosis Through Touch. 2nd ed. Edinburgh ; New York: Churchill Livingstone; 2003.


13. O'Connor DP, Fincher AL. Clinical Pathology for Athletic Trainers. Thorofare, N.J.: Slack; 2008.

14. Gorse K, Blanc R, Feld F, Radelet M. Emergency Care in Athletic Training. 1st ed: F.A. Davis; 2010.

15. Andress A. Saunders Textbook of Medical Office Management. 2 ed. St. Louis: Elsevier Science; 2003.

16. Konin JG, Frederick M. Documentation for Athletic Training. Thorofare: SLACK Incorporated; 2005.

Performance Domain 3: Immediate and Emergency Care

The profession of athletic training is unique in that the Athletic Trainer (AT) may be present at the time of an injury or emergency. This requires that the AT be prepared and proficient in all aspects of emergency care.1 As the profession of athletic training continues to evolve and practice settings emerge, the ability to deal with emergent situations will remain a constant and very critical challenge.

Coordinate care of individual(s) through appropriate communication (e.g., verbal, written, demonstrative) of assessment findings to pertinent individual(s).

Preparation is the key to success for all ATs. It is vital that an appropriate Emergency Action Plan (EAP) be prepared for every venue for which the AT is responsible.2‐5 This preparation must occur prior to an emergency by creating clear and easily located documents and protocols, so that all involved parties have knowledge of their specific roles and

responsibilities.2,6 The EAP should be reviewed yearly with all involved parties, ensuring that appropriate and coordinated action can occur in an emergency.2,5,7‐9 Appropriate communication between the AT and other health care providers, particularly EMS, will lead to a smooth transition of care in the event of an emergency.3,10 The AT must be able to demonstrate excellent communication skills, either verbal or written, in order to transfer vital assessment information to the EMT, physician, parent, coaches, supervisors and others that are involved in the care of the patient.2,10

Apply the appropriate immediate and emergency care procedures to prevent the exacerbation of non‐life‐threatening and life‐threatening health‐related conditions, reducing the risk factors for morbidity and mortality.

The recognition of signs and symptoms of life threatening conditions is the cornerstone of effective management of these conditions. ATs must have a vast knowledge of medical conditions which can


quickly become emergencies such as asthma11,12, sickle cell trait13, hypertension and diabetes14. This is also the case for environmental conditions such as heat15, cold16 and lightning5,17. Quick and decisive action is imperative in preventing conditions from deteriorating and becoming life threatening.5,15,18 It is essential that ATs are able to effectively provide emergency care for a wide range of injuries and conditions ranging from, but not limited to: sudden cardiac arrest5,9,19, compound fractures and dislocations, wound care20, respiratory illness and distress11,12, head and cervical trauma7,18,21‐24, infectious diseases20,25 and traumatic organ injuries26,27.3,4,10,28

To assess and effectively administer emergency medical care, the AT must be proficient in utilizing a variety of medical equipment such as AEDs, splints, sphygmomanometers (BP cuffs) and stethoscopes.3,5,8,10,19,29 Once assessed, the AT is charged with providing immediate and appropriate medical treatment until additional medical personnel/ treatment becomes available. All ATs must maintain up‐to‐date emergency cardiac care certification and must be compliant with state, federal and licensing regulations that dictate scope of practice and implement referral when warranted.1,3,29

For the immediate management of all conditions, the AT should remain current in the appropriate utilization of modalities and pharmacological interventions.11,14,30‐32 The AT is required to make prudent medical decisions regarding return to activity and provide protection from further injury through taping, padding, bracing or splinting if indicated.3,28,33

Implement appropriate referral strategies, while stabilizing and/or preventing exacerbation of the condition(s), to facilitate the timely transfer of care for health‐related conditions beyond the scope of practice of the Athletic Trainer.

Certain injuries and illnesses may require care that warrants referral. It is necessary for the AT to be able to recognize these conditions and select the most effective and safest method to transport the individual

to the appropriate medical provider.3,6 Proficiency in splinting and immobilization is required even in the presence of complicated athletic equipment and atypical locations (i.e. pool, ice rink, pit).4,7,18,33 Knowledge of specific equipment as well as its safe removal is imperative for the timely deliverance of care.7,18,22,33

Psychological conditions such as eating disorders, depression and anxiety can become medical emergencies if warning signs are not recognized. Appropriate referral strategies should be in place in the event an emergent situation occurs.3,34,35

Demonstrate how to implement and direct immediate care strategies (e.g., first aid, Emergency Action Plan) using established communication and administrative practices to provide effective care.

Education of all involved parties allows for expedient care and treatment of the patient as well as appropriate home care. The AT should be able to develop plans and protocols that include signage, letters and brochures to alert those around them of their roles in the management of injuries and emergencies.2,6,21,24 The AT may have to direct those that have no medical background in the execution of the EAP, and must be able to communicate care instructions at a level that is appropriate for a lay person as well as medical personnel. EAPs and spine boarding should be reviewed and rehearsed with all involved parties on a regular basis.5,7

All injuries and emergency situations need to be appropriately and accurately documented utilizing injury and incident reports for legal considerations as well as internal debriefing and review.2,4,6,36 The AT must protect the individual’s personal medical information as stated in Health Insurance Portability and Accountability Act (HIPAA).1,3,6 The AT can also contribute to the profession by sharing interesting and unusual cases through evidence‐based scholarly writing and presentations.1,3


ID Description

Domain 3 Immediate and emergency care – Employing standard care procedures and communicating outcomes for efficient and appropriate care of the injured.

0301 Coordinate care of individual(s) through appropriate communication (e.g., verbal, written, demonstrative) of assessment findings to pertinent individual(s).

Knowledge of

Components of the emergency action plan(s)


Roles of individual members of the medical management team

Skill in

Communicating effectively with appropriate individuals (e.g., medical providers, patients, parents, administrators)

Educating individuals regarding standard emergency care procedures

Implementing the emergency action plan(s)

0302 Apply appropriate immediate and emergency care procedures to prevent the exacerbation of health‐related conditions to reduce the risk factors for morbidity and mortality.

Knowledge of

Appropriate management techniques for life‐threatening health‐related conditions (e.g., respiratory, cardiac and central nervous)

Appropriate use of emergency equipment and techniques (e.g., AED, CPR masks, and BP cuff)

Mechanisms (biomechanics/kinesiology)of catastrophic conditions

Common life‐threatening medical situations (e.g., respiratory, central nervous, and cardiovascular)

Emergency action plan(s)

Federal and state occupational, safety, and health guidelines Human physiology: normal and compromised functions

Physiologic reactions to life‐threatening conditions Pharmacological and therapeutic modality usage for acute health‐related conditions

Signs and symptoms of common medical conditions

Standard protective equipment and removal devices and procedures

Skill in

Applying pharmacological agents

Applying therapeutic modalities

Performing cardio‐pulmonary resuscitation techniques and procedures

Implementing emergency action plan(s)

Implementing federal and state occupational, safety, and health guidelines

Implementing immobilization and transfer techniques

Managing common non‐life‐threatening and life‐threatening emergency situations/health‐related conditions (e.g., evaluation, monitoring, and provision of care)

Measuring, monitoring, and interpreting vital signs

Removing protective equipment using appropriate removal devices and/or manual techniques

Transferring care to appropriate medical and/or allied health professionals and/or facilities

Using standard medical equipment

Utilizing emergency equipment

0303 Implement appropriate referral strategies, while stabilizing and/or preventing exacerbation of the condition(s), to facilitate the timely transfer of care for health‐related conditions beyond the scope of practice of the Athletic Trainer.

Knowledge of

Common management strategies for life‐ and non‐life‐threatening health‐related conditions


Health‐related conditions beyond the scope of the athletic trainer Indications for referral to other health care providers Roles of medical and allied health care providers

Skill in


Directing a referral to the appropriate professionals Immobilization, splinting and transfer techniques

Implementing the emergency action plan(s)

Managing common non‐life‐threatening and life‐threatening emergency situations/health‐related conditions until transfer to appropriate medical providers and facilities

Recognizing acute health‐related conditions beyond the scope of the athletic trainer


ID Description

0304 Demonstrate how to implement and direct immediate care strategies (e.g., first aid, Emergency Action Plan) using established communication and administrative practices to provide effective care.

Knowledge of



Evidence based practice Pertinent administrative practices

Roles of medical and allied health care providers

Skill in Implementing the emergency action plan(s)

Implementing relevant administrative practices (e.g., Injury reports, documentation, case reports)

Instruction of emergency care techniques

References

1. Board of Certification. BOC Standards of Professional Practice. http://www.bocatc.org/; 2006.





6. Rankin JM. Athletic Training Management:Concepts and Applications. 3rd ed. Boston, MA: McGraw Hill; 2006.

7. Swartz EE, Boden BP, Courson RW, et al. National athletic trainers' association position statement: acute management of the cervical spine‐injured athlete. J Athl Train. May‐Jun 2009;44(3):306‐331.



10. Rehberg RS, ed. Sports Emergency Care: A Team Approach. Thorofare, N.J.: Slack; 2007.


12. Storms WW. Exercise‐induced bronchospasm. Curr Sports Med Rep. Mar‐Apr 2009;8(2):45‐46.

13. Anderson S, Eichner ER. Consensus Statement: Sickle cell trait and the athlete. J Athl Training. 2007 2007.


15. ACSM, Armstrong LE, Casa DJ, et al. Exertional heat illness during training and competition. American College of Sports Medicine Position Stand. Med Sci Sport Exer. 2007;39(3):556‐572.


16. Cappaert TA, Stone JA, Castellani JW, Krause BA, Smith D, Stephens BA. National Athletic Trainers' Association position statement: environmental cold injuries. J Athl Training. 2008;43(6):640‐658.

17. Edlich RF, Farinholt HM, Winters KL, Britt LD, Long WB, 3rd. Modern concepts of treatment and prevention of lightning injuries. J Long Term Eff Med Implants. 2005;15(2):185‐196.

18. Bailes JE, Petschauer M, Guskiewicz KM, Marano G. Management of cervical spine injuries in athletes. J Athl Training. 2007;42(1):126‐134.

19. ARC. CPR/AED for the Professional Rescurer. 1st ed: Staywell; 2006.

20. OSHA. Laws, regulations, interpretations FAQ Bloodborne pathogens. Available at: http://www.osha.gov/comp‐links.html, 2008.

21. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Athl Train. Jul‐Aug 2009;44(4):434‐448.

22. Cantu RC, Mueller FO. The prevention of catastrophic head and spine injuries in high school and college sports. Br J Sports Med. Dec 2009;43(13):981‐986.

23. Romeo SJ, Hawley CJ, Romeo MW, Romeo JP. Facial injuries in sports: A team physician's guide to diagnosis and treatment. Physician Sportsmed. April 2005 2005;33(4).

24. Guskiewicz KM, Bruce SL, Cantu RC, et al. National Athletic Trainers' Association Position Statement: Management of Sport‐Related Concussion. J Athl Train. Sep 2004;39(3):280‐297.

25. Clem KL, Borchers JR. HIV and the athlete. Clin Sports Med. Jul 2007;26(3):413‐424.

26. Tiemstra JD, Kapoor S. Evaluation of scrotal masses. Am Fam Physician. Nov 15 2008;78(10):1165‐1170.

27. Koester M. Initial evaluation and management of acute scrotal pain. J Athl Training. 2000;35(1):76‐79.


29. AHA. Available at: http://www.americanheart.org/, November 2009.

30. Prentice WE, ed. Therapeutic Modalities for Sports Medicine and Athletic Training. 6th ed. New York: McGraw‐Hill Higher Education; 2009.

31. Denegar CR, Saliba E, Saliba S. Therapeutic Modalities for Musculoskeletal Injuries. 2nd ed. Champaign, IL: Human Kinetics; 2010.

32. Magnus B, Miller B. Pharmacology Application in Athletic Training; 2005.

33. Honsik K, Boyd A, Rubin AL. Sideline splinting, bracing, and casting of extremity injuries. Curr Sports Med Rep. Jun 2003;2(3):147‐154.

34. Leone JE, Sedory EJ, Gray KA. Recognition and treatment of muscle dysmorphia and related body image disorders. J Athl Training. 2005;40(4):352‐359.


36. Ray R. Management Strategies in Athletic Training. 3rd ed. Champaign, IL: Human Kinetics; 2006.


Performance Domain 4: Treatment and Rehabilitation

Following injury, the athletic trainer (AT) serves as the clinician who plans, administers, and executes a plan of care. Included within this plan of care is the implementation of appropriate techniques, procedures, practices, and methods which are designed to provide the patient with optimal outcomes.1‐9 Throughout the plan of care, the clinician reassesses the patient’s overall status, current state of the injury or illness, and his or her response to treatment/rehabilitation applications.1,3,4,7,10‐13 Effective and appropriate communication to the patient and other individuals concerned with the patient’s care, protection from additional insult, and appropriate progressions towards optimal recovery are included in the ATs plan and execution of care.3,4,6,11,14‐18

Acting under the direction of a physician and within the state’s practice act and/or BOC Standards of Professional Practice, the AT provides a plan of care, which is based upon the problems realized through assessment and examination of the patient.3,4,7,9,10,13,16‐26 The treatment program is designed to relieve problems and restore function to optimal levels. Treatment objectives are outlined using short‐term and long‐term goals.4,22,23,27 These goals are achieved using appropriate treatment/rehabilitation methods available to the clinician. Selection of these various treatment/rehabilitation modes are based on sound rationale, appropriate standards of health care, reliable clinical judgment, and when available, evidence‐based medicine.1,4,5,11,28

Administer therapeutic and conditioning exercise(s) using appropriate techniques and procedures in order to aid recovery and restoration of function.

The ability to apply and utilize appropriate techniques and procedures in therapeutic and conditioning programs is founded on the AT’s knowledge base in anatomy, physiology, and kinesiology of normal tissues and organ systems, as well as anatomical pathology, pathophysiology, and pathokinesiology related to injury and illness.16,18,25,29‐60 The AT designs a treatment program based on the healing phase,

progression through the healing process, and the level of stress most appropriate to healing tissue at that time.3,4,7,9,11,61 In the case of surgical procedures, the AT incorporates appropriate therapeutic treatment and rehabilitation techniques with the knowledge, understanding, and appreciation of tissues impacted by the surgical procedure, restrictions and protections required, and progression time‐lines most appropriate for the specific structures involved.4,10,11,20,62‐65 The AT applies rehabilitation techniques most appropriate for patients of various ages, adjusting techniques and demands to match age‐adjusted expectations, specific growth and development stages of younger patients, express considerations and adjustment requirements of older patients, and special factors which must be taken into account for unique patient populations.4,8,10,14,31,33,66,67

The AT should be attuned to special situations that may arise during rehabilitation. Since all aspects of care have their own specific indications, contraindications, and precautions, the AT selects treatment options based on these considerations and is sensitive to them throughout all aspects of rehabilitation.1,11,21,25,44,52,56,62,68‐73 The AT maintains awareness of medications commonly used by patients that may either affect treatment or is affected by treatment; adjustments in rehabilitation are made when appropriate for these specific patients.47,74‐80

Much of the rehabilitation program involves the use of exercise. Exercise may be used to recover many deficiencies in the rehabilitation patient. The AT possesses knowledge of the theories and principles of cardiovascular and neuromuscular treatment, rehabilitation and reconditioning as well as the adaptations which occur in the body following these activities.1,4,15,28,37,39,44,47,64,65,69,70,72,73,75,81‐87 Principles of aerobic and anaerobic conditioning, adaptation and overload of tissues, adaptations of various systems, and neural adaptations such as improvement in proprioception and kinesthesis are applied to program progressions as part of the treatment, rehabilitation and reconditioning process.1,4,15,28,37,39,44,47,64,65,67,69,70,72,73,75,81‐88 The rehabilitation program, then, includes cardiovascular, flexibility, strength, muscle endurance, balance and proprioception, agility, and coordination exercises.4,15,28,39,64,67,69,73,82,83,86,89‐94


Numerous forms of equipment, tools, and methods of exercise are available in rehabilitation. The AT’s knowledge of these various pieces of equipment, their indications and contraindications, and how to apply them in the rehabilitation and reconditioning program provides for an optimal program for the patient. ATs may use the following therapeutic exercise techniques as part of a routine rehabilitation program: isometric, isotonic, and isokinetic exercises, along with strength, power, and speed activities.1,4,15,28,64,65,67,69,82,86,89,92,94,95 Additional exercises used in more specific rehabilitation programs may include core stabilization, plyometrics, and agility activities.4,10,28,64,82,86,89,92 Additional treatments such as aquatic exercise, isokinetics, closed‐ and open chain activities are also included within the AT’s realm of treatment techniques.4,10,15,28,44,64,81,82,86,93

Throughout the rehabilitation process, the AT is aware of the psychological impact both injury and recovery have on the patient.36 As the patient continues through the rehabilitation program, the AT should take into consideration the patient’s psychological adjustment and alter the rehabilitation program as necessary.1,4,15,28,36

The AT should also realize the expectations made of the patient when he or she returns to normal function, normal being beyond activities of daily living. The AT should use this knowledge to create, provide, and adjust appropriate rehabilitation exercises throughout the rehabilitation process. Once the patient moves into the last phase of rehabilitation, the AT prepares the patient for re‐entry to normal functional activities. Understanding the patient’s normal activities is imperative to establishing reliable return‐to‐activity assessment tools. The AT should establish the most appropriate criteria and evaluate the patient’s ability to correctly perform each criteria before the patient is allowed to return to his or her prior level of pre‐injury participation.1,64,69,81,82,96‐98 An AT must have an appreciation and understanding of the biomechanical and kinesiological factors involved in the patient’s activity, as well as the flexibility, strength and power, and coordination and agility demands of the activity, in order to create an accurate assessment that will reliably test the patient’s readiness for normal participation.1,4,11,15,28,64,69,81,82,84,96‐101 Final release of

the patient which permits a full return to participation is provided by the physician, often based upon the AT’s recommendations.

Administer therapeutic modalities (e.g., electromagnetic, manual, mechanical) using appropriate techniques and procedures based on the individual’s phase of recovery to restore functioning.

Therapeutic modalities are used in rehabilitation to facilitate and optimize healing, reduce pain and edema, and prepare tissue for therapeutic exercise.3,7,9,17,71 The AT possesses knowledge of the body’s inflammatory and healing process and how the application of each modality may impact the physiology of this healing process. The AT also understands the theories of pain and how modalities modify the patient’s pain response. The AT should also understand the use of physician‐prescribed pharmaceutical products as they relate to therapeutic modality selection and application.3,7,9,17,71

ATs are trained to use a wide variety of therapeutic modality agents. These agents may be generally categorized as manual, mechanical, electromagnetic, and acoustical energy. Included within these categories are various joint and soft tissue manual therapies, manual and mechanical traction, thermal modalities, various forms of electrical stimulation, biofeedback, laser, diathermies, and ultrasound.3,7,9,17,71 ATs should use their knowledge of the principles, indications, contraindications, precautions, and application of therapeutic modalities to determine the most appropriate modality for each patient.3,7,9,17,71

In the conscientious application of any therapeutic care, the AT recognizes and adheres to standards of care regarding blood‐borne pathogens, open wound care, and potential infections including those of bacterial, viral, fungal, and parasitic origin. In addition, the AT recognizes either the onset of systemic illness, or changes in the patient’s status regarding systemic illnesses, and provides prompt referral to qualified professionals for continued care and treatment when appropriate.

Apply braces, splints, or other assistive devices according to appropriate practices in order to


facilitate injury protection to achieve optimal functioning for the individual.

During the rehabilitation process, the use of orthotics and other assistive devices may be necessary to protect or support an injured segment or assist in restoring function. Any choice of orthotic or assistive device may be used to achieve the ultimate goal of optimal restoration. Such devices may include supportive or protective casting, braces or splints, splints or machines to encourage or restrict motion, orthotics to protect or facilitate proper biomechanics, dynamic or static splints, and various assistive devices used to restrict, limit, or protect against full weight bearing of the lower extremities.1,14,24,100 Such devices may be commercially available soft goods, rigid materials, machines, or other equipment designed to support, protect, restrict, facilitate, or limit a body segment. These devices may be generically constructed or custom‐made. They may be used at any time throughout the rehabilitation program, depending on their use, intent, healing phase of the injury site, and age and physiological status of the patient.

The AT must be aware of numerous factors when using these devices. The AT must be knowledgeable of the materials, fabrication, function, and application of each type of orthotic and assistive device. The AT must be equally knowledgeable regarding the selection of the most appropriate device to use, based on the pathomechanics of each specific injury or condition warranting such a device.1,14,24,100 Each device may have legal restrictions when it comes to participation in various athletic events or work environments; the AT must be cognizant of and abide by these regulations regarding use of these devices during play or work.1,14,24,100

The AT should be able to provide recommendations for, or construction of, appropriate devices when an orthotic or assistive device is warranted. Application of the brace, splint, other orthotic, or assistive devices is performed by the AT. The AT should adhere to requirements for physician‐prescription needs regarding the use of any orthotic or assistive device, as well as other state or institutional regulations.1,14,24,100,102

Administer treatment for injury, illness, and/or health‐related conditions using appropriate methods to facilitate injury, protection, recovery, and/or optimal functioning for individual(s).

Although ATs primarily encounter neuromuscular and musculoskeletal injuries, ATs may also serve as a primary health care provider to patients with illnesses or other health conditions affecting different systems of the body. The AT must be knowledgeable of the physiology and pathophysiology of the cardiovascular; hematological; pulmonary; gastrointestinal; hepatic‐biliary; endocrine; metabolic; eye, ears, nose, and throat (EENT); neurological; genitourinary; integumentary; psychological; and immune systems of the body.29,31,32,50,54,103‐109 ATs should possess knowledge of the most common pathologies that affect these systems which may include systemic illnesses, communicable diseases, and infections of bacterial, viral, fungal, and parasitic origins.35,54,110,111

As part of the management and referral of these conditions, ATs must possess knowledge of pharmacology and how pharmaceuticals may impact injury, illness, and disease.75‐78,80 The AT must recognize the psychological impact of injury, illness, and disease, as well as how the structure, growth, development, and regeneration of organs and the patient’s body are impacted by these conditions.36,54,74,75,77,78,80,110‐112 The AT should have multiple medical and health‐care professionals available for referrals, and must understand when to refer patients for appropriate care.36,54,74,75,77,78,80,110‐112 The AT is able to determine the indications which require referral, recognize the status of systemic illnesses where referral is appropriate, and identify bacterial, viral, fungal, and parasitic infections that are best managed by a medical or other health care professional.35,54,110‐112 The decision to refer a patient should be made in a timely and efficient manner, and the AT should communicate appropriately with these professionals regarding referral and treatment.

In cases where referral for additional care is not necessary, the AT shall provide appropriate treatment and assessment of open wounds and dermatological conditions under the direction of a physician35,54,110‐112. The AT must use appropriate blood‐borne precautions, sterile and clean techniques in the care,


treatment, and dressing of wounds and dermatological conditions as directed by the physician.35,54,55,107,108,110‐112 The AT may use additional thermal, electrical, mechanical, and acoustical modalities to encourage healing or restrict infection during the care of these conditions.3,7,9,17,71

Reassess the status of injuries, illnesses, and/or health‐related conditions using appropriate techniques and documentation strategies to determine appropriate treatment, rehabilitation, and/or reconditioning and to evaluate readiness to return to a desired level of activity.

Continual and ongoing re‐assessment of the patient’s condition is an important aspect of the rehabilitation and reconditioning process. With appropriate treatment, the patient’s condition is expected to change and ultimately improve to optimal levels of function. Re‐assessment allows the AT to monitor and provide appropriate care. Re‐assessment techniques are based on the AT’s knowledge of recovery level, recovery rate, and performance level, always considering the age‐ and injury‐specific factors that influence recovery. The AT must have an appreciation for the potential of the cardiovascular and musculoskeletal systems to recover and perform at expected levels.

Regular re‐assessment and establishment of new short‐term goals is part of the rehabilitation process.4,15,28,37,38,96 These goals are based upon the accomplishment of prior short‐term goals and the expectation to advance to a new level of recovery.4,15,28,37,38,96 These expectations are based upon the individual’s response to treatment as well as the AT’s knowledge of the principles of tissue adaptation and application of overload, physiological effects of strength and conditioning exercises, and effects of various methods of therapeutic exercise.4,15,28,37,38,96 The AT must also consider neuromuscular factors that both influence and are influenced by rehabilitation, such as proprioception, kinesthesis, and other neurological connections4,15,28,37,38,96 Therapeutic exercise techniques may incorporate the use of various methods of strength and conditioning; including plyometrics, core stabilization, speed, agility, power, and endurance exercises.1,4,10,15,28,39,64,65,67,69,82,86,89,92,94

The AT should select the most appropriate treatment options based on the combination of the indications, precautions, and contraindications of each specific technique, stage of recovery, and performance needs of the patient. Each rehabilitation technique should address problems identified through frequent assessment and re‐assessment, as well as the goals established for that patient.4,11,15,28,38,96

In order to anticipate proper goals of patients, the AT must have knowledge of the healing process of specific tissues involved in the injury, illness or disease; realize the implications of age‐related influences on the specific structures involved as well as the potential for growth, development, and regeneration of affected tissues; and understand the adaptation process which occurs with both the injury, illness, or disease and the treatment of these conditions.1,4,10,15,16,24,28,35,50,54,60,67,68,86,111 Systems of the body frequently adapt to alterations in their function or structure following injury or disease; the AT must remain aware of these changes and consider them as a treatment program is planned and goals are established.

Basic to a treatment program for an orthopedic injury is an understanding of how the neuromuscular and musculoskeletal systems function, while knowledge of physiology and pathophysiology is crucial in the care of individuals with illness or disease.4,42,44,51,64,67,73,86 The psychological impact injury, illness, or disease may have on the individual is also crucially important for the athletic trainer to understand. Just as understanding the changes that occur with treatment of neuromuscular and musculoskeletal conditions, how treatment may impact psychological responses to these conditions is also an important aspect of AT treatment. Additionally, in the case of surgical procedures, ATs must have knowledge of the impact specific procedures have on rehabilitation protocols, patient physical and emotional reaction, rate of recovery, and performance.4,10,15,28

All ATs should follow appropriate documentation protocols for initial findings, periodic re‐evaluations, and all treatments.22,23,27 Cooperative communication between the AT and other health professionals involved in the care and treatment of patients is important to the successful outcome of the


rehabilitation program. The AT often serves as the primary care giver and other health care providers often rely heavily upon the AT for information, assistance, and communication regarding ongoing care and treatment for specific patients. Documentation is often exchanged between appropriate parties to assure optimal treatment results.

The AT’s rehabilitation responsibility is not only performing examinations and re‐examinations, but also interpreting the information gathered from these examinations to provide an accurate assessment of each patient’s rehabilitation progress and reaction to care and treatment.4,11,38,42 Each element of the treatment program should be assessed for its benefit and the patient’s ability to achieve established goals. The patient’s response to each of these elements is also assessed. Depending on the AT’s assessment of the patient’s response to the rehabilitation program, it may be necessary to modify, continue, or discontinue any aspect of treatment.4,11,38,42

The AT must be able to identify functional criteria required for a patient to resume full activity.4,64,69,82,83,90,91,113 These criteria are based upon the AT’s knowledge of the patient’s responsibilities, and the AT’s skill in providing activities that recreate those skills and abilities the patient must demonstrate to resume normal function. Once established, the criteria are used to evaluate the patient’s readiness to return normal function.4,64,69,82,83,90,91,113 The patient’s ability to return to normal function is determined by the physician, but he or she often relies on AT’s assessment.

Provide guidance and/or referral to specialist for individual(s) and groups thorough appropriate communication strategies (e.g., oral and education materials) to restore an individual(s) optimal functioning.

The AT has a responsibility to assure patient compliance during the rehabilitation process.3,4,15,28,71 Compliance is enhanced by communication with the patient regarding established goals, assigned home exercises, and the rationale for activities included in the program. The AT must effectively communicate the rationale for restrictions to the patient, and

provide why careful adherence to protocols is essential for full recovery. Compliance is improved when the patient is kept informed throughout the rehabilitation process.3,4,15,28,71

Education includes both verbal and written instructions. Written instructions often provide better compliance and are provided when most appropriate. These written instructions may help the AT outline the rehabilitation process to the patient, and how compliance will lead to rehabilitation success. When available, the use of videos, pamphlets, posters, models, and handouts provide the patient with additional information related to expectations and also offer both rapid understanding and long‐term outlooks for the patient.3,4,15,28,71,96

Information provided to the patient by the AT must be age‐appropriate so the patient is able to comprehend the information and utilize the provided instructions to optimize treatment results. The AT must utilize simple language when communicating with patients. Professional terminology is most appropriate when communicating with other health care professionals.3,4,15,28,71,96 In some instances, patient education may be improved by communicating with a parent or other family member; the AT makes this determination based on the patient’s age, involvement, communication and comprehension abilities, perception, reception, and willingness to participate.

When the AT communicates with the patient and/or family members, considerations for the potential psychological effects of such discussions should be taken into account. Sensitivity and respect are incorporated into the communication process throughout the rehabilitation program.3,4,15,28,71,96

It is not uncommon for patients to require assistance in their psychological recovery during rehabilitation following injury, illness or disease. The AT must be sensitive to this possibility and have referral sources in place if this need arises. The AT should remain vigilant for psychological or emotional signs and symptoms that indicate the need for referral. The AT should identify possible support systems such as family, friends, community groups, psychosocial programs, and community assistance when


appropriate.4,15,35,36,41,54,68,100,114 Additionally, the AT must remain aware of referral sources and utilize them when indicated.4,15,35,36,41,54,68,100,114

The AT must maintain appropriate communication to other health professionals regarding referral and treatment for individuals while following HIPAA regulations,. The AT is able to identify the indications

and need for referral and directs those referrals to the most appropriate and qualified health care professional. Knowing when and to whom to refer for treatment, guidance, counseling throughout the treatment, rehabilitation, and reconditioning process is part of the AT’s responsibilities as a health care provider.

ID Description

Domain 4 Treatment and rehabilitation – Reconditioning participants for optimal performance and function.

0401 Administer therapeutic and conditioning exercise(s) using appropriate techniques and procedures to aid recovery and restoration of function.

Knowledge of

Adaptation of the cardiovascular and muscular systems related to treatment, rehabilitation, and reconditioning

Age‐specific considerations related to treatment, rehabilitation, and reconditioning

Available equipment and tools related to treatment, rehabilitation, and reconditioning

Functional criteria for return to activity Indications and contraindications related to treatment, rehabilitation, and reconditioning

Inflammatory process related to treatment, rehabilitation, and reconditioning

Neurology related to treatment, rehabilitation, and reconditioning

Pharmacology related to treatment, rehabilitation, and reconditioning

Principles of adaptation and overload of tissues Principles of adaptation of systems

Principles of strength and conditioning exercises (e.g., plyometrics, core stabilization, speed, agility, and power)

Principles of therapeutic exercise (e.g., isometric, isotonic, isokinetic, work, power, and endurance)

Proprioception and kinesthesis related to treatment, rehabilitation, and reconditioning

Psychology related to treatment, rehabilitation, and reconditioning

Structure, growth, development, and regeneration of tissue

Surgical procedures and implications for treatment, rehabilitation, and reconditioning

Skill in Applying exercise prescription in the development and implementation of treatment, rehabilitation, and reconditioning (e.g., aquatics, isokinetics, and closed‐chain)

Evaluating criteria for return to activity

0402 Administer therapeutic modalities (e.g., electromagnetic, manual, mechanical) using appropriate techniques and procedures based on the individual’s phase of recovery to restore functioning.

Knowledge of

Available therapeutic modalities related to treatment, rehabilitation, and reconditioning

Indications and contraindications for therapeutic modalities

Inflammatory process related to therapeutic modalities

Pharmacology related to therapeutic modalities

Physiological response to therapeutic modalities

Principles of mechanical, electromagnetic, and acoustical energy



Theories of pain

Skill in

Applying manual therapy techniques

Applying thermal, electrical, mechanical, and acoustical modalities


Recognizing the status of systemic illnesses

Recognizing the status of bacterial, viral, fungal, and parasitic infections

0403 Apply braces, splints, or other assistive devices according to appropriate practices in order to facilitate injury protection to achieve optimal functioning for the individual.


ID Description

Knowledge of

Commercially available soft goods

Functions of bracing Legal risks and ramifications for bracing

Pathomechanics of common and catastrophic injury

Materials and methods for fabricating custom‐made devices

Pathomechanics of the injury or condition

Skill in Applying braces, splints, or assistive devices Fabricating braces, splints, or assistive devices

0404 Administer treatment for injury, illness, and/or health‐related conditions using appropriate methods to facilitate injury protection, recovery, and/or optimal functioning for individual(s).

Knowledge of

Available reference sources related to injuries, illnesses, and health‐related conditions Medical and allied health care professionals involved in the treatment of injuries, illnesses, and health‐related conditions

Pathophysiology associated with systemic illness, communicable diseases, and infections (e.g., bacterial, viral, fungal, and parasitic)

Pharmacology related to the treatment of injuries, illnesses, and health‐related conditions

Psychological reaction to injuries, illnesses, and health‐related conditions Structure, growth, development, and regeneration of tissue

Skill in

Applying topical wound or skin care products Applying thermal, electrical, mechanical, and acoustical modalities


Directing a referral to the appropriate professionals Indications for referral Recognizing the status of systemic illnesses

Recognizing the status of bacterial, viral, fungal, and parasitic infections

0405 Reassess the status of injuries, illnesses, and/or health‐related conditions using appropriate techniques and documentation strategies to determine appropriate treatment, rehabilitation, and/or reconditioning and to evaluate readiness to return to a desired level of activity.

Knowledge of

Adaptation of the cardiovascular and muscular systems related to rehabilitation, recovery, and performance

Age‐specific considerations related to rehabilitation, recovery, and performance

Appropriate documentation protocols

Functional criteria for return to activity Indications and contraindications related to rehabilitation, recovery, and performance

Inflammatory process related to rehabilitation, recovery, and performance

Neurology related to rehabilitation, recovery, and performance

Principles of adaptation and overload of tissues Principles of strength and conditioning exercises (e.g., plyometrics, core stabilization, speed, agility, and power)


Proprioception and kinesthesis related to rehabilitation, recovery, and performance

Psychology effects related to rehabilitation, recovery, and performance


Surgical procedures and implications for rehabilitation, recovery, and performance

Skill in Evaluating criteria for return to activity Interpreting assessment information necessary to modify, continue, or discontinue treatment plans

0406 Provide guidance and/or referral to specialist for individual(s) and groups through appropriate communication strategies (e.g., oral and education materials) to restore an individual(s) optimal functioning.


ID Description

Knowledge of

Applicable methods and materials for education

Appropriate documentation protocols

Available support systems (e.g., psychosocial, community, family, and health care) related to rehabilitation, recovery, and performance


Learning process across the lifespan Psychology effects related to rehabilitation, recovery, and performance

Referral resources

Skill in


Directing a referral to the appropriate professionals Identifying appropriate individuals to educate Indications for referral Providing guidance/counseling for the individual during the treatment, rehabilitation, and reconditioning process

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42. Magee DJ. Orthopedic Physical Assessment. 5th ed. St. Louis, MO: Saunders Elsevier; 2008.

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45. McKeown C. Office Ergonomics: Practical Applications. Boca Raton, FL: CRC Press; 2008.

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47. Mirzayan R. Cartilage Injury in the Athlete. New York: Thieme; 2006.

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56. Rehberg RS, ed. Sports Emergency Care: A Team Approach. Thorofare, N.J.: Slack; 2007.

57. Scifers JR. Special Tests for Neurologic Examination. Thorofare, NJ: SLACK; 2008.

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63. Henrichs A. A review of knee dislocations. Journal of Athletic Training. 2004;39(4):365‐369.

64. Kibler WB, Herring SA, Press JM. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Austin, TX: Pro‐Ed; 2005.

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Performance Domain 5: Organizational and professional health and well‐being

Athletic trainers (ATs) are charged with many responsibilities including: (1) injury/illness prevention and wellness protection, (2) clinical evaluation and diagnosis, (3) immediate and emergency care, and (4) treatment and rehabilitation. However, in order to properly implement any type of comprehensive athletic training services, an organization must demonstrate and support an appropriate level of organizational and professional health and well‐being.

Organizational, professional and individual well‐being is built on the foundation of understanding and adhering to: (1) approved organization and professional practices, standards, and guidelines (2) federal statutes, and (3) state statutes which apply to the practice and/or organization and administration of athletic training. Whether covering a youth soccer tournament, working in one of several hospital satellite clinics, or running a collegiate athletic training program, the AT relies on these practices, standards, and guidelines. Maintenance of records and accurate documentation is mandatory for communication, reimbursement, risk management, and determining best practices.3‐7 Emergency action plans with consideration for staffing, coordination of resources, liability, and equipment reduce the risk to the individual and organization.5,8 When organizing a health care team or making referrals related to injuries, illness and unhealthy lifestyle behaviors, the AT must be knowledgeable of their scope of practice and the state statutes that regulate their profession

and the health professionals with whom they work.2,5,6,9 For organizations and professionals to maintain financial health, the AT must demonstrate the ability to utilize basic internal business skills including strategic planning, human resource management, budgeting, and facility design. They must be able to apply external business skills, such as marketing and public relations to support organizational sustainability, growth, and development.2,5,6,10

The role of an AT is constantly evolving. Today, as health care professionals providing a wide range of reimbursable medical and management services to a diverse patient population, it is vital to understand not only the organizational culture, but demonstrating the necessary management skills for organizational, professional, and personal growth.2,6 Currently, 47 states have some form of athletic training state regulation, providing statutory and regulatory provisions for the practice of athletic training to provide for the safety and welfare of individual(s) and groups. ATs also possess two CPT billing codes designated specifically for athletic injury evaluation, and share billing codes for physical medicine and rehabilitation with several other health care professionals.

As the recognition and respect for the profession of Athletic Training has grown, other health care organizations have sought the expertise of ATs and work in conjunction with the profession to produce consensus and positions statements on topics such as but not limited to: (1) exertional heat illness, (2) fluid


replacement, (3) lightening safety, (4) management of the diabetic, cervical‐spine injured, asthmatic, and sickle cell athlete, and (6) emergency planning and preparedness for sudden cardiac death. The integration of evidence based medicine is another important aspect in the growth and development of the profession.11 According to Steves and Hootman (2004) “Athletic trainers need to embrace the critical‐thinking skills to assess the medical literature and incorporate it into their clinical practice. The profession should encourage more clinically related research and enhance the scientific foundation of athletic training.”11

Apply basic internal business functions (e.g., business planning, financial operations, staffing) to support individual and organizational and organizational growth and development.

The establishment and management of effective Athletic Training services begins with strategic planning. This includes setting goals and objectives aligned with accreditation standards for the facility or program. The AT must direct the program with leadership styles and management techniques that are most appropriate for the setting.7,10

Selection and management of a skilled staff is paramount to an effective program. The AT must have knowledge of institutional and federal employment regulations prior to the selection of staff members.12,13 Consistent performance evaluations, delegation of duties, and scheduling are human resource skills that are vital to the AT manager.7,10

The AT must be adept at managing the budgetary element of the program. This requires knowledge of inventory control, bidding processes, and institutional purchasing procedures.7,10 With the constant evolution of the healthcare business, ATs must be vigilant in their familiarity of the legal and financial implications for reimbursement, including return on investment.7,10,14,15

The AT must be able to select computer hardware and software that will meet the demands of their practice setting, such as billing, injury tracking, concussion management, and documentation.2,6,7

Apply basic external business functions (e.g., marketing and public relations) to support organizational sustainability, growth, and development.

The sustainability and growth of any professional healthcare service is dependent on strong business practices. ATs must utilize management and leadership techniques to compete in today’s healthcare market.2,5 In order to maximize their return on investment, ATs must balance their inventory and purchasing decisions with their expected reimbursement for their services. Marketing and public relations skills are vital to the success of the program.5,7,10

Maintain records and documentation that comply with the organizational, association, and regulatory standards to provide quality of care and to enable internal surveillance for program validation and evidence‐based interventions.

Documentation skills permeate every aspect of the AT profession. Documentation of injuries and treatments of patients must be performed using standard medical terminology and comply with Federal, State, and accreditation standards (e.g., HIPAA, Buckley Amendment, etc.).4,14,15

Valid and reliable evidence‐based research, utilizing accurate and detailed documentation of outcomes has advanced the esteem of ATs. They continue to advance their knowledge and skills through their own research as well as interpreting and evaluating available literature.11,16‐21 The vast knowledge that is now accessible through technology allows ATs to implement effective programs. Policy and position statements from appropriate professional organizations are utilized when designing pre‐participation physicals, drug testing, and risk management programs.22‐25 When hiring or contracting services, ATs can access and interpret professional standards and guidelines for various professionals. They must know and act according to the statues and regulations that govern their practice.7,10,12,13

Demonstrate appropriate planning for coordination of resources (e.g., personnel, equipment, liability,


scope of service) in event medical management and emergency action plans.

A vital role of the AT is the prevention of injuries and recognition of incidents (injury or illness) during events such as practices, competitions, rehabilitation or while sponsoring and/or managing athletic events. Therefore, it is crucial to have a thorough understanding of how to design, prepare, implement, and manage appropriate medical coverage5,6,23,25 and emergency action plans5,6,26‐28 during athletic events in order to prevent unwanted lawsuits or legal actions, often associated with negligence because of poor planning and preparation.

The emergency action plan is a written document defining not only the actions of the AT, but other medical personnel when an emergency situation arises5,6,26‐28 such as acute cervical spine injury management,29,30 sudden cardiac arrest,31,32 and lightning.33 Emergency action plans should be designed, reviewed, and implemented by ATs working in all organizational settings and not just institutions sponsoring athletic activities or events.27,34,35 An emergency action plan should clearly articulate to all parties, including the AT staff, physicians, coaches, administrators, and emergency medical services the specific personnel, communication, equipment procedures, transportation, emergency care facility, and documentation that are required in the event of an emergency.26,36‐38 Emergency action plans should be developed by organizational or institutional personnel in consultation with the local emergency medical services27 and should be reviewed by the organization’s or institution’s legal counsel and/or administrators before officially posted and implemented.5,6,39 Once developed, emergency action plans should be reviewed and rehearsed annually in conjunction with all involved parties and modified with written documentation of any such modifications.27,39

Organizational and institutional management of resources, patient safety, appropriate health care delivery, and legal compliance is a monumental task, requiring appropriate documentation to prevent unwanted lawsuits or legal actions.5,6,10 Understanding the criteria used for establishing legal standards of care in athletic training such as Federal and State

statutes and the Board of Certification Standards of Professional Practice12 is the first step in demonstrating appropriate planning and coordination of medical services. The delivery of appropriate health care begins with reading, interpreting, and designing organization and institutional policy around federal statutes and regulations such as blood‐borne pathogens24,40,41, administration of medication42‐45, and patient confidentiality.

Patient safety requires focusing on protecting the patient while engaged in activity and protecting the AT themselves. Establishing and implementing pre‐participation physical examination policies reduces organizational and institutional risk by identify pre‐existing and life‐threatening conditions and identifying disqualifying conditions before allowing participation.6,10 Organizational and institutional implementation of drug testing and substance abuse policies according to the appropriate governing body promote fairness and equitable competition and safeguard the health and safety of the athletes by discouraging drug use and abuse. Obtaining, interpreting, evaluating, and applying relevant policy and position statements established by organizations such as the National Athletic Trainers’ Association27,30,33,46‐49, American College of Sports Medicine50‐53, and joint policy and position statements54‐56 protects patients and ATs by ensuring the appropriate standard of care is applied during an emergency and reduces risk and liability respectively.

Demonstrate an understanding of statutory and regulatory provisions and professional standards of the practice of Athletic Training in order to provide for the safety and welfare of individual(s) and groups.

The safety and welfare of the individual(s) and groups under the care of an AT is the number one priority of the Board of Certification (BOC) and this is clearly delineated in the BOC Standards of Professional Practice.12 The BOC Standards of Professional Practice consists of two sections: (1) Practice Standards and (2) Code of Professional Responsibility. The Practice Standards establish the essential practice expectations for all ATs and are intended to: (1) assist the public in understanding what to expect from an AT, (2) assist the AT in evaluating the quality of patient care, and (3)


assist the AT in understanding the duties and obligations imposed by virtue of holding the ATC® credential.12 The Code of Professional Responsibility (Code) mandates that BOC credential holders and applicants act in a professionally responsible manner in all athletic training services and activities. Failure to uphold the Code can result in discipline, revocation or take other some other form of action with regard to the application or certification of an individual that does not adhere to the Code.12

Pursuant to the ability to demonstrate an understanding of the statutory and regulatory provisions of practice as an AT to ensure safety and welfare of individual(s) and groups is the ability to abide by and implement the standards set forth by individual state practice and title acts, federal government, and supporting organizations (i.e., NCAA, NAIA, NFSHSA). Specific issues relative to ensuring the safety and welfare of individuals and groups includes issues such as, but not limited to: (1) maintenance of facilities and equipment24,57‐59 (2) medical and administrative documentation4,5, (3) ensuring safe playing and treatment environments34,60,61, (4) researching evidence based‐practice procedures11,20,62,63, and demonstrating and understanding medical ethics and the law.64

Develop a support/referral process for interventions to address unhealthy lifestyle behaviors.

The establishment and management of effective support/referral process for the management of unhealthy lifestyle behaviors begins with an understanding of pathophysiology, psychosocial, and at‐risk groups in order make appropriate support/referral decisions. Unhealthy life behaviors of concern, may include, but are not limited to: (1) alcohol consumption, (2) drugs (i.e., amphetamines, ephedrine, ma huang, anabolic‐androgenic steroids, barbiturates, caffeine, cocaine, heroin, LSD, PCP, marijuana), (3) tobacco of all forms (smoke and smokeless), (4) unhealthy diet, (5) sexually transmitted infections and exposure to potential blood borne pathogens (i.e., HBV and HIV).,(6) physical inactivity.24,34,65‐70 Three modifiable lifestyle behaviors,

(1) smoking, (2) unhealthy diet, and (3) physical inactivity have been associated with the development of chronic diseases including heart disease, cancer, stroke, and diabetes.68,71,72

Development of a support/referral team for intervention requires identifying qualified providers who have the requisite training for early case detection, treatment, and psychological support needed to address the potential lifestyle behaviors noted above.9,67,73 Providers should represent multiple medical (appropriately credentialed) and community disciplines, including, but not limited to (1) medicine, (2) nutrition, (3) mental health, (4) wellness and health promotion (5) athletic training, (6) administrators, and possibly (7) risk‐management personnel and legal counsel. All providers should work together to formulate and implement a comprehensive management protocol complete with well defined policies and procedures that facilitate early detection, accurate assessment, and treatment of patients demonstrating unhealthy lifestyle behaviors.67

Support/referral providers should be able to demonstrate the ability to be (1) readily accessible and able demonstrate the ability accurately assess, treat, refer, and follow‐up with patients depending upon each individual situation, (2) understand not only their individual roles and responsibilities, but the roles and responsibilities of other providers, (3) demonstrate appropriate professional behaviors, (4) promote collaboration to facilitate a seamless continuum of care, and (5) be able to identifying and use appropriate resources to educate at‐risk patients.12,34,67,73 Furthermore, individuals providing intervention for unhealthy lifestyle behaviors must clearly understand and demonstrate appropriate levels of patient confidentiality12,64,74 and respect for diversity, as well understand what type(s) of behavior(s)/situation(s) require the involvement of a third party (e.g., coach, administrator)6 in order to remain in compliance with federal and statues, regulations, and adjunction which applies to the practice and/or organization and administration of athletic training programs.


ID Description

Domain 5 Organizational and professional health and well‐being – Understanding and adhering to approved organizational and professional practices and guidelines to ensure individual and organizational well‐being.

0501 Apply basic internal business functions (e.g., business planning, financial operations, staffing) to support individual and organizational growth and development.

Knowledge of

Appropriate computer software applications

Credentialing systems and general requirements for pertinent professions

Facility design and operation Human resource management

Institutional budgeting and procurement process

Institutional and federal employment regulations (e.g., EEOC, ADA, and Title IX)

Management techniques

Leadership styles Revenue generation strategies Staff scheduling, patient flow, and allocation of resources Storage and inventory procedures Strategic planning and goal setting

Skill in

Facility design, operation, and management (e.g., planning, organizing, designing, scheduling, coordinating, budgeting)

Managing financial resources (e.g., planning, budgeting, resource allocation, revenue generation)

Managing human resources (e.g., delegating, planning, staffing, hiring, firing, and conducting performance evaluations)

Using computer software applications (e.g., word processing, data base spreadsheet, and Internet applications)

0502 Apply basic external business functions (e.g., marketing and public relations) to support organizational sustainability, growth, and development.

Knowledge of



Facility design and operation Human resource management

Institutional budgeting and procurement process

Institutional and federal employment regulations (e.g., EEOC, ADA, and Title IX)

Management techniques

Leadership styles Revenue generation strategies Staff scheduling, patient flow, and allocation of resources Storage and inventory procedures Strategic planning and goal setting

Skill in

Facility design, operation, and management (e.g., planning, organizing, designing, scheduling, coordinating, budgeting)

Managing financial resources (e.g., planning, budgeting, resource allocation, revenue generation)

Managing human resources (e.g., delegating, planning, staffing, hiring, firing, and conducting performance evaluations

Using computer software applications (e.g., word processing, data base spreadsheet, and Internet applications)

0503 Maintain records and documentation that comply with organizational, association, and regulatory standards to provide quality of care and to enable internal surveillance for program validation and evidence‐based interventions.


ID Description

Knowledge of



Criteria for determining the legal standard of care in athletic training (e.g., state statutes and regulations, professional standards and guidelines, publications, customs, practices, and societal expectations)

Evidence‐based practice, epidemiology studies, and clinical outcomes assessment

Federal and state statutes, regulations, and adjudication that apply to the practice and/or organization and administration of athletic training (e.g., OSHA, DEA, Title IX, Civil Rights Act, HIPAA, Buckley Amendment, labor practices, patient confidentiality, insurance, and record keeping)

Guidelines and regulations for decreasing exposure to environmental hazards

Guidelines for development of risk management policies and procedures

Institutional drug testing and substance abuse policies Institutional, governmental, and appropriate organizational guidelines for safety, health care delivery, and legal compliance

Institutional review boards, policies, and procedures regarding informed consent guidelines

Institutional risk management policies and procedures

Prescreening participation guidelines Relevant policy and position statements of appropriate organizations (e.g., ACSM, AOASM, AOSSM, AMSSM, NCAA, NATA, NFHSA, NAIA, USOC)

Standard medical terminology and nomenclature

State statutes, regulations, and adjudication that directly govern the practice of athletic training (e.g, state practice and title acts, state professional conduct and misconduct acts, liability and negligence)

State statutes, regulations, and adjudication governing other professions which impact the practice of athletic training (e.g., medicine, physical therapy, nursing, pharmacology)

Skill in

Creating and completing the documentation process

Obtaining, interpreting, evaluating, and applying relevant research data, literature, and/or other forms of information

Obtaining, interpreting, evaluating, and applying relevant policy and position statements

Interacting with appropriate administration leadership

Researching practice methods and procedures

Researching professional standards and guidelines (e.g., BOC, NATA, state organizations) Using computer software applications (e.g., word processing, data base spreadsheet, and Internet applications)

0504 Demonstrate appropriate planning for coordination of resources (e.g., personnel, equipment, liability, scope of service) in event medical management and emergency action plans.

Knowledge of

Appropriate medical equipment and supplies


Federal and state statutes, regulations, and adjudication that apply to the practice and/or organization and administration of athletic training (e.g., OSHA, DEA, Title IX, Civil Rights Act, HIPAA, Buckley Amendment, labor practices, patient confidentiality, insurance, and record keeping)

Institutional drug testing and substance abuse policies Institutional, governmental, and appropriate organizational guidelines for safety, health care delivery, and legal compliance

Institutional review boards, policies, and procedures regarding informed consent guidelines

Institutional risk management policies and procedures

Prescreening participation guidelines Reimbursement issues

Staff preparedness State statutes, regulations, and adjudication that directly govern the practice of athletic training (e.g., state practice and title acts, state professional conduct and misconducts acts, liability and negligence)

State statutes, regulations, and adjudication governing other professions that impact the practice of athletic training (e.g., medicine, physical therapy, nursing, pharmacology)

Site‐specific access issues


ID Description

Skill in

Creating and completing the documentation process

Interacting with appropriate administration leadership

Obtaining, interpreting, evaluating, and applying relevant policy and position statements

Researching practice methods and procedures

Researching professional standards and guidelines (e.g., BOC, NATA, state organizations) Using computer software applications (e.g., word processing, data base spreadsheet, and Internet applications)

0505 Demonstrate an understanding of statutory and regulatory provisions and professional standards of the practice of Athletic Training in order to provide for the safety and welfare of individual(s) and groups.

Knowledge of

Appropriate equipment and facility inspection procedures and documentation


Federal and state statutes, regulations, and adjudication which apply to the practice and/or organization and administration of athletic training (e.g., OSHA, DEA, Title IX, Civil Rights Act, HIPAA, Buckley Amendment, labor practices, patient confidentiality, insurance, record keeping)

Institutional, professional, and governmental guidelines for maintenance of facilities and equipment

Manufacturer’s operational guidelines

Safe playing and treatment environments

State statutes, regulations, and adjudication that directly govern the practice of athletic training (e.g, state practice and title acts, state professional conduct and misconducts acts, liability and negligence)

State statutes, regulations, and adjudication governing other professions which impact the practice of athletic training (e.g., medicine, physical therapy, nursing, pharmacology)

Skill in Researching and applying state and federal statutes, regulations, and adjudications Researching professional standards and guidelines (e.g., BOC, NATA, state organizations) Researching practice methods and procedures

0506 Develop a support/referral process for interventions to address unhealthy lifestyle behaviors.

Knowledge of

Appropriate professional behaviors Credentialing systems and general requirements for health care professions

Community resources

Confidentiality policies Effective communication techniques (e.g., multimedia videos, pamphlets, posters, models, handouts, and oral communication)

Effective meeting planning

Federal and state statutes, regulations, and adjudication which apply to the practice and/or organization and administration of athletic training (e.g., OSHA, DEA, Title IX, Civil Rights Act, HIPAA, Buckley Amendment, labor practices, patient confidentiality, insurance, record keeping)

Institutional and governmental regulations regarding drug use, substance abuse, and mental illness

Institutional chain of command

Role and scope of practice of various health care professionals

Skill in


Directing a referral to the appropriate professionals Identifying appropriate individuals to educate Indications for referral Interpreting standard medical terminology and nomenclature for appropriate individuals

Mitigating conflict

Networking and recruiting qualified medical team members

Nurturing professional relationships Providing guidance/counseling for the individual during the treatment, rehabilitation, and reconditioning process

Respecting diversity of opinions and positions


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Bibliography

Domain 1

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ACSM (1987). "Position stand: The use of anabolic‐androgenic steroids in sports." Med Sci Sports Exer 19(5): 534‐539.

ACSM (2000). "Nutrition and athletic performance." Med Sci Sports Exer 32(12): 2130‐2145.

ACSM (2007). "Exercise and acute cardiovascular events: placing the risks into perspective." Med Sci Sport Exer 39(5): 886‐897.

ACSM (2007). "Exercise and fluid replacement." Med Sci Sport Exer 39(2): 377‐390.

ACSM and AHA (2002). "Joint Position Statement: automated external defibrillators in health/fitness facilities." Med Sci Sports Exer 34(3): 561‐564.


ACSM, A. Albright, et al. (2000). "Position Statement: Exercise and type 2 diabetes." Med Sci Sport Exer 32(7): 1345‐1360.

ACSM, L. E. Armstrong, et al. (2007). "Exertional heat illness during training and competition. American College of Sports Medicine Position Stand." Med Sci Sport Exer 39(3): 556‐572.

ACSM, J. W. Castellani, et al. (2006). "Prevention of cold injuries during exercise." Med Sci Sport Exer 38(11): 2012‐2029.

ACSM, J. M. Jakicic, et al. (2001). "Appropriate intervention strategies for weight loss and prevention of weight regain for adults." Med Sci Sport Exer 33(12): 2145‐2156.

ACSM, W. M. Kohrt, et al. (2004). "Physical activity and bone health." Med Sci Sport Exer 36(11): 1985‐1996.

ACSM, W. J. Kraemer, et al. (2002). "Progression models in resistance training for healthy adults." Med Sci Sport Exer 34(2): 364‐380.

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ACSM, A. Nattiv, et al. (2007). "The female athlete triad." Med Sci Sport Exer 39(10): 1867‐1882.

ACSM, R. A. Oppliger, et al. (1996). "Position Stand: weight loss in wrestlers." Med Sci Sports Exer 28(10): 135‐138.

ACSM, L. S. Pescatello, et al. (2004). "Exercise and hypertension." Med Sci Sport Exer 36(3): 533‐553.

ACSM, M. L. Pollock, et al. (1998). "Position Stand: recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults " Med Sci Sports Exer 30(6): 975‐991.

ACSM, M. N. Sawka, et al. (1996). "Position Stand: The use of blood doping as an ergogenic aid." Med Sci Sports Exer 28(3): i‐vii.

ACSM, B. Zinman, et al. (1997). "Diabetes Mellitus and Exercise." Med Sci Sport Exer 29(12): 1‐6.

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Hillman, S. K. (2005). Introduction to Athletic Training, Human Kinetics.

Kleiner, D. M., A. J.L., et al. (2003). "Prehospital care of the spine‐injured athlete." Clin J Sport Med 13(1): 59‐61.


Mays, D. and N. Thompson (2009). "Alcohol‐Related Risk Behaviors and Sports Participation Among Adolescentys: An Analysis fo 2005 Youth Risk Behavior Data." J. of Adolescent Health 44(1): 87‐89.

NATA (2003). "Official Statement ‐ Automated External Defibrillators."

NATA (2005). "Age Specific Task Force Issue on Youth Football & Heat Related Illness."

NATA (2005). "Official Statement on Community‐Acquired MRSA Infections (CA‐MRSA)." J Athl Training.

NATA (2005). "Official Statement on Steroids & Performance Enhancing Substances."

NATA (2007). "Official Statement on Commotio Cordis."

NATA (2007). "Official Statement on Communicable and Infectious Diseases in Secondary School Sports." J Athl Training.

NATA (2009). "NATA Code of Ethics." from http://www.nata.org/codeofethics/code_of_ethics.pdf.

NATA, J. Almquist, et al. (2004). "Appropriate medical care for secondary school‐age athletes communication." Retrieved May 31, 2008, from http://www.nata.org/statements/support/secondary_school_medcarecommunication.pdf.

NATA, J. C. Andersen, et al. (2002). "Position Statement: Emergency planning in athletics." J Athl Training 37(1): 99‐104.

NATA, H. M. Binkley, et al. (2002). "Postion Statement: Exertional heat illness." J Athl Training 37(3): 329‐343.

NATA, J. F. Heck, et al. (2004). "Position Statement: Head‐down contact and spearing in tackle football." J Athl Training 39(1): 101‐111.

NATA, C. C. Jimenez, et al. (2007). "Position Statement: Management of the athlete with Type 1 diabetes mellitus." J Athl Training 42(4): 536‐545.

NATA, M. G. Miller, et al. (2005). "Position Statement: Management of asthma in athletes." J Athl Training 40(3): 224‐245.

NATA, K. M. Walsh, et al. (2000). "Position Statement: Lightning safety for athletics and recreation." J Athl Training 35(4): 471‐477.

NATA, e. a. (2007). "Recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs."

NATA, I. t., J. A. Drezner, et al. (2007). "Inter‐Association Task Force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: A consensus statement." J Athl Training 42(1): 143‐158.

NCAA (2009). "Wrestling Rules and Interpretations." 81‐90.

NCAA, N. a. (2004). "“PLAY‐BY‐PLAY” Sport Specific Results and Recommendations 16‐Year Review of NCAA Injury Surveillance System (ISS) Data." J Athl Training.

Online, M. M. (2009). "Screening for Sports: Cardiovascular."

Domain 2

Anderson, M. K., G. P. Parr, et al. (2009). Foundations of Athletic Training Philadelphia, PA, Wolters Kluwer Health/Lippincott Williams & Wilkins.

Bahr, R. and S. Mµhlum (2004). Clinical Guide to Sports Injuries. Campaign, IL, Human Kinetics.



Chaitow, L. (2003). Palpation and Assessment Skills : Assessment and Diagnosis Through Touch. Edinburgh ; New York, Churchill Livingstone.

Child, Z. (2007). Basic Orthopedic Exams. Philadelphia, Wolters Kluwer/Lippincott Williams & Wilkins.

Cummings, N., Stamley‐Green, S. Higgs P (2008). Perspectives in Athletic Training, Elsevier Mosby.

Cuppett, M. and K. M. Walsh (2005). General Medical Conditions in the Athlete. St. Louis, Mosby.

Dolan, M. G. (2008). Management of Acute Athletic Trauma and Illnesses.

Eustace, S. J. (2007). Sports Injuries: Examination, Imaging, and Management. Edinburgh ; New York, Churchill Livingstone/Elsevier.

Evans, R. W., Ed. (2006). Neurology and Trauma. New York, Oxford University Press.

Field, D. (2006). Anatomy: Palpation and Surface Markings. Oxford ; Boston, Butterworth Heinemann.

Hebestreit, H., O. Bar‐Or, et al. (2008). The Young Athlete. Malden, Mass., Blackwell Pub.

Holcomb, W. (2002). Practical Skills Manual for Evaluation of Athletic Injuries. Philadelphia, F.A. Davis.

Houglum, J. E., G. L. Harrelson, et al. (2005). Principles of Pharmacology for Athletic Trainers. Thorofare, N.J., Slack, Inc.

Kendall, F. P. (2005). Muscle Testing and Function with Posture and Pain, Lippincott, Williams & Wilkins.

Koester, M. C. (2007). Therapeutic Medications in Athletic Training. Champaign, IL, Human Kinetics.

Konin, J. G. (2006). Special Tests for Orthopedic Examination. Thorofare, NJ, SLACK.

Konin, J. G. and M. Frederick (2005). Documentation for Athletic Training. Thorofare, SLACK Incorporated.

Loudon, J. K., M. Swift, et al. (2008). The Clinical Orthopedic Assessment Guide. Champaign, IL, Human Kinetics.

Magnus, B. and B. Miller (2005). Pharmacology Application in Athletic Training.

McMahon, P. J. (2007). Current Diagnosis & Treatment in Sports Medicine. New York, Lange Medical Books/McGraw Hill Medical Pub. Division.

Mirzayan, R. (2006). Cartilage Injury in the Athlete. New York, Thieme.

NATA, D. J. Casa, et al. (2000). "Position Statement: Fluid replacement for athletes." J Athl Training 35(2): 212‐224.




O'Connor, D. P. and A. L. Fincher (2008). Clinical Pathology for Athletic Trainers. Thorofare, N.J., Slack.

Pfeiffer, R. P. and B. C. Mangus (2008). Concepts of Athletic Training. Sudbury, MA, Jones and Bartlett.

Prentice, W. E. (2009). Arnheim's Principles of Athletic Training. Boston, McGraw‐Hill Higher Educaiton.

Prentice, W. E. and D. D. Arnheim (2008). Essentials of Athletic Injury Management. Boston, McGraw‐Hill.


Schwellnus, M., IOC Medical Commission., et al. (2008). The Olympic Textbook of Medicine in Sport. Malden, Mass., Blackwell Pub.

Shultz, S. J., P. A. Houglum, et al. (2009). Examination of Musculoskeletal Injuries. Champaign, IL, Human Kinetics.

Starkey, C., G. Johnson, et al., Eds. (2006). Athletic Training and Sports Medicine Sudbury, Mass, Jones and Bartlett.

Starkey, C. and J. L. Ryan (2003). Orthopedic and Athletic Injury Evaluation Handbook. Philadelphia, F.A. Davis.

Tixa, S. (2008). Atlas of Surface Palpation : Anatomy of the Neck, Trunk, Upper and Lower Limbs. Edinburgh; New York, Churchill Livingstone Elsevier.

Domain 3

AHA. November 2009, from http://www.americanheart.org/.

Anderson, M. K. (2002). Fundamentals of Sports Injury Management. Philadelphia, PA, Lippincott, Williams and Wilkins.

Appenzeller, H. (2005). Risk Management in Sport: Issues and Strategies Durham, NC, Carolina Academic Press.

ARC (2006). CPR/AED for the Professional Rescurer, Staywell.

ARC (2007). "American Red Cross: Health and Safety Services." from www.redcross.org.

Bailes, J. E., M. Petschauer, et al. (2007). "Management of cervical spine injuries in athletes." J Athl Training 42(1): 126‐134.

Binkley, H. M., T. Schroyer, et al. (2003). "Latex allergies: A review of recognition, evaulation, management, prevention, education, and alternative product use." J Athl Training 38(2): 133‐140.

Board of Certification (2006). BOC Standards of Professional Practice. http://www.bocatc.org/.


Cappaert, T. A., J. A. Stone, et al. (2008). "National Athletic Trainers' Association position statement: environmental cold injuries." J Athl Training 43(6): 640‐658.

Crossman, J. (2001). Coping with Sports Injuries: Psychological Strategies for Rehabilitation. New York, NY, Oxford University Press.

Hannam, S. (2000). Professional Behavior in Athletic Training. Thorofare, NJ, Slack Publishers.

Henrichs, A. (2004). "A review of knee dislocations." J Athl Training 39(4): 365‐369.

Honsik, K. A. (2004). "Emergency treatment of dentoalveolar trauma." Physician Sportsmed 32(9).

Houglum, J. (2000). "Asthma Medications: Basic Pharmacology." J Athl Training 35(2): 179‐187.

Kleiner, D. M., J. L. Almquist, et al. (2001). Prehospital care of the spine‐injured athlete: A Document from the Inter‐Assoication Task Force for the appropriate care of the spine‐injured athlete. Inter‐Association Task Force for Spine Care. Dallas, TX, National Athletic Trainers' Association.

Koester, M. (2000). "Initial evaluation and management of acute scrotal pain." J Athl Training 35(1): 76‐79.

Leone, J. E., E. J. Sedory, et al. (2005). "Recognition and treatment of muscle dysmorphia and related body image disorders." J Athl Training 40(4): 352‐359.

Lynch, S. A. (2002). "Assessment of the injured ankle in the athlete." J Athl Training 37(4): 406‐412.


McChesney, J. A. and J. W. McChesney (2001). "Ausculation of the chest and abdomen by athletic trainers." J Athl Training 36(36): 190‐196.

Mueller, F. O. (2001). "Catastrophic head injuries in high school and college sports." J Athl Training 36(3): 312‐315.







NATA, I. t., J. A. Drezner, et al. (2007). "Inter‐Association Task Force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: A consensus statement." J Athl Training 42(1): 143‐158.

NCAA (2008). "Blood borne pathogens and intercollegiate athletics." NCAA Sports Medicine Handbook. 2008, from http://www.ncaa.org/wps/ncaa?ContentID=1446.

OSHA (2008). "Laws, regulations, interpretations FAQ Bloodborne pathogens." 2008, from http://www.osha.gov/comp‐links.html.

Preboth, M. (2000). "Risk of HIV infection in the athletic setting." Am Fam Physician 61(5): 1561.


Rankin, J. M. (2006). Athletic Training Management:Concepts and Applications. Boston, MA, McGraw Hill.

Ray, R. (2006). Management Strategies in Athletic Training. Champaign, IL, Human Kinetics.

Romeo, S. J., C. J. Hawley, et al. (2005). "Facial injuries in sports: A team physician's guide to diagnosis and treatment." Physician Sportsmed 33(4).

Schottke, D. and AAOS (2007). First Responder: Your First Response in Emergency Care. Chicago, Il, Jones and Bartlett Publishers.

Schwartz, E. E., B. P. Boden, et al. (2009). "National athletic trainers' association position statement: acute management of hte cervical spine‐injured athlete." J Athl Training 44(3): 306‐331.

Terry, G. C., J. M. Kyle, et al. (2001). "Sudden cardiac arrest in athletic medicine." J Athl Training 36(2): 205‐209.

Turner, H. S. (2003). "Athletic training services and student health services on campus: Working together." J Am Coll Health 51(5): 217‐220.

Waninger, K. N. (2004). "Management of the helmeted athlete with suspected cervical spine injury." Am J Sports Med 32(5): 1331‐1350.

Domain 4


ACSM, J. W. Castellani, et al. (2006). "Prevention of cold injuries during exercise." Med Sci Sport Exer 38(11): 2012‐2029.

ACSM, W. M. Kohrt, et al. (2004). "Physical activity and bone health." Med Sci Sport Exer 36(11): 1985‐1996.

ACSM, W. J. Kraemer, et al. (2002). "Progression models in resistance training for healthy adults." Med Sci Sport Exer 34(2): 364‐380.

ACSM, A. Nattiv, et al. (2007). "The female athlete triad." Med Sci Sport Exer 39(10): 1867‐1882.

ACSM, L. S. Pescatello, et al. (2004). "Exercise and hypertension." Med Sci Sport Exer 36(3): 533‐553.

Adler, S. S., D. Beckers, et al. (2008). PNF in Practice: An Illustrated Guide. Heidelberg, Springer Medizin Verlag.

AMA (1993). American Medical Association Handbook of First Aid & Emergency Care. New York, Random House.

Andrews, E. (2005). Muscle Management for Musicians. Lanham, MD, Scarecrow Press.

Andrews, J. R., G. L. Harrelson, et al., Eds. (2004). Rehabilitation of the Injured Athlete. Philadelphia, W.B. Saunders.

Archer, P. A. (2007). Therapeutic Massage in Athletics. Baltimore, Lippincott Williams & Wilkins.

Baechle, T. R. and R. W. Earle, Eds. (2008). Essentials of Strength Training and Conditioning Champaign, IL, Human Kinetics.


Borcherding, S. and M. J. Morreale (2007). The OTA's Guide to Writing SOAP Notes. Thorofare, N.J., Slack.

Boyle, M. (2004). Functional Training for Sports. Champaign, IL, Human Kinetics.

Bridger, R. S. (2008). Introduction to Ergonomics. Boca Raton, FL, Taylor & Francis.

Cameron, M. H. (2008). Physical Agents in Rehabilitation: From Research to Practice. St. Louis, Mosby.

Carayon, P., Ed. (2007). Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, N.J., Lawrence Erlbaum Associates.

Chaffin, D. B., G. B. J. Andersson, et al. (2006). Occupational Biomechanics. Hoboken, N.J., Wiley‐Interscience.

Chandler, T. J. and L. E. Brown, Eds. (2008). Conditioning for Strength and Human Performance. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins.

Chu, D. (2003). Plyometric Exercises with the Medicine Ball. Livermore, CA, Bittersweet Pub.

Cioppa‐Mosca, J., J. B. Cahill, et al., Eds. (2008). Handbook of Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician. St. Louis, Mosby.

Cohen, B. J. (2005). Memmler's the Human Body in Health and Disease Philadelphia, Lippincott Williams & Wilkins.

Corrigan, B. and G. D. Maitland (1983). Practical Orthopaedic Medicine. London, Butterworths.

Crowley, L. V. (2007). An Introduction to Human Disease: Pathology and Pathophysiology Correlations. Sudbury, MA, Jones and Bartlett.

Cuppett, M. and K. M. Walsh (2005). General Medical Conditions in the Athlete. St. Louis, Mosby.

Davidovits, P. (2008). Physics in Biology and Medicine. Boston, Elsevier / Academic Press.

Delavier, F. (2006). Strength Training Anatomy. Champaign, IL, Human Kinetics.


DeLee, J. C. and D. Drez, Eds. (2003). DeLee & Drez's Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, PA, Saunders.

Denegar, C. R., E. Saliba, et al. (2010). Therapeutic Modalities for Musculoskeletal Injuries. Champaign, IL, Human Kinetics.

Dutton, M. (2002). Manual Therapy of the Spine. New York, McGraw‐Hill Medical Pub. Division.

Dutton, M. (2004). Orthopaedic Examination, Evaluation, & Intervention. Chicago, McGraw‐Hill.

Evans, R. W., Ed. (2006). Neurology and Trauma. New York, Oxford University Press.

Finkham, S. (2004). Athletic Training in Occupational Settings. Thorofare, N.J., Slack.

Fleck, S. J. and W. J. Kraemer (2004). Designing Resistance Training Programs. Champaign, IL, Human Kinetics.

Flegel, M. J. (2004). Sport First Aid. Champaign, IL, Human Kinetics.

Frederick, A. and C. Frederick (2006). Stretch to Win. Champaign, IL, Human Kinetics.

Gambetta, V. (2007). Athletic Development: The Art & Science of Functional Sport Conditioning. Champaign, IL, Human Kinetics.

Gantz, N. M., R. B. Brown, et al. (2006). Manual of Clinical Problems in Infectious Disease. Philadelphia, Lippincott Williams & Wilkins.

Greenman, P. E. (2003). Principles of Manual Medicine. Philadelphia, Lippincott Williams & WIlkins.

Hall, C. M. and L. T. Brody (2005). Therapeutic Exercise: Moving Toward Function. Philadelphia, Lippincott Williams & Wilkins.

Hamilton, N., W. Weimar, et al. (2008). Kinesiology: Scientific Basis of Human Motion. Boston, McGraw‐Hill Higher Education.

Hammer, W. I., Ed. (2007). Functional Soft‐Tissue Examination and Treatment by Manual Methods. Sudbury, MA, Jones and Bartlett.

Haywood, K. M. and N. Getchell (2009). Life Span Motor Development. Champaign, IL, Human Kinetics.

Hecox, B., Ed. (2006). Integrating Physical Agents in Rehabilitation. Upper Saddle River, N.J., Pearson/Prentice Hall.

Heyward, V. H. (2006). Advanced Fitness Assessment and Exercise Prescription. Champaign, IL, Human Kinetics.

Higgins, R., B. English, et al., Eds. (2006). Essential Sports Medicine. Malden, Mass, Blackwell.

Hislop, H. J. and J. Montgomery (2007). Daniels and Worthingham's Muscle Testing: Techniques of Manual Examination. Philadelphia, W.B. Saunders.

Holt, L. E. (2008). Flexibility: A Concise Guide. Totowa, N.J., Humana.

Houglum, J. E., G. L. Harrelson, et al. (2005). Principles of Pharmacology for Athletic Trainers. Thorofare, N.J., Slack, Inc.

Houglum, P. A. (2010). Therapeutic Exercise for Musculoskeletal Injuries. Champaign, IL, Human Kinetics.

Howse, J. (2000). Dance Technique & Injury Prevention. New York, Routledge.

Hyde, T. E. and M. S. Gengenbach (2007). Conservative Management of Sports Injuries. Sudbury, MA, Jones and Bartlett.

Johnson, D. L. and S. D. Mair, Eds. (2006). Clinical Sports Medicine. Philadelphia, PA, Mosby Elsevier.


Jurch, S. E. (2009). Clinical Massage Therapy: Assessment and Treatment of Orthopedic Conditions. Boston, McGraw‐Hill Higher Education.

Kaltenborn, F. M. (2007). Manual Mobilization of the Joints: The Extremities. Oslo, Norway, Norli.

Kaminsky, L. A. and ACSM, Eds. (2006). ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription / American College of Sports Medicine. Baltimore, Lippincott Williams & Wilkins.

Karageanes, S. J. (2005). Principles of Manual Sports Medicine. Philadelphia, Lippincott Williams & Wilkins.

Keag, D. B. and J. Moeller, Eds. (2007). ACSM’s Primary Care Sports Medicine. Philadelphia, PA, Lippincott Williams & Wilkins.

Kibler, W. B., S. A. Herring, et al. (2005). Functional Rehabilitation of Sports and Musculoskeletal Injuries. Austin, TX, Pro‐Ed.

Kisner, C. and L. A. Colby (2007). Therapeutic Exercise: Foundations and Techniques. Philadelphia, F.A. Davis.

Knight, K. L. and D. O. Draper (2008). Therapeutic Modalities: The Art and the Science. Baltimore, Lippincott Williams & Wilkins.

Koester, M. C. (2007). Therapeutic Medications in Athletic Training. Champaign, IL, Human Kinetics.

Kumar, S., Ed. (2008). Biomechanics in Ergonomics. Boca Raton, FL, Taylor & Francis.

Kumbhare, D. A. and J. V. Basmajian, Eds. (2000). Decision Making and Outcomes in Sports Rehabilitation. New York, Churchill Livingstone.

Lederman, E. (2005). The Science and Practice of Manual Therapy. New York, Elsevier/Churchill Livingstone.

Levangie, P. K. and C. C. Norkin (2005). Joint Structure and Function: A Comprehensive Analysis. Philadelphia, F.A. Davis.

Liebenson, C., Ed. (2007). Rehabilitation of the Spine: A Practioner's Manual. Philadelphia, Lippincott Williams & Wilkins.

MacAuley, D. and T. M. Best, Eds. (2007). Evidence‐Based Sports Medicine. Malden, Mass, Blackwell.

MacLaren, D. (2007). Nutrition and Sport. New York, Elsevier.

Maitland, G. D., E. Hengeveld, et al. (2005). Maitland's Vertebral Manipulation. Boston, Butterworth‐Heinemann.

McArdle, W. D., F. I. Katch, et al. (2007). Exercise Physiology: Energy, Nutrition, and Human Performance. Philadelphia, Lippincott Williams & Wilkins.

McAtee, R. E. (2007). Facilitated Stretching. Champaign, IL, Human Kinetics.

McKeown, C. (2008). Office Ergonomics: Practical Applications. Boca Raton, FL, CRC Press.

Michlovitz, S. L. and T. P. Nolan, Eds. (2005). Modalities for Therapeutic Intervention. Philadelphia, F.A. Davis.








Neumann, D. A. (2009). Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. St. Louis, Mosby.

Norkin, C. C. and D. J. White (2009). Measurement of Joint Motion. A Guide to Goniometry. Philadelphia, F.A. Davis.

Oatis, C. A. (2009). Kinesiology: The Mechanics and Pathomechanics of Human Movement. Baltimore, Lippincott Williams & Wilkins.

O'Connor, D. P. and A. L. Fincher (2008). Clinical Pathology for Athletic Trainers. Thorofare, N.J., Slack.

Perry, J. (1992). Gait Analysis: Normal and Pathological Function. Thorofare, N.J., Slack.

Pfeiffer, R. P. and B. C. Mangus (2008). Concepts of Athletic Training. Sudbury, MA, Jones and Bartlett.


Prentice, W. E., Ed. (2009). Therapeutic Modalities for Sports Medicine and Athletic Training. New York, McGraw‐Hill Higher Education.

Roach, S. and T. Lochhaas (2005). Pharmacology for Health Professionals. Philadelphia, Lippincott Williams & Wilkins.

Robinson, A. J. and L. Snyder‐Mackler (2008). Clinical Electrophysiology: Electrotherapy and Electrophysiology Testing. Philadelphia, Lippincott Williams & Wilkins.

Rose, J. and J. G. Gamble, Eds. (2006). Human Walking. Philadelphia, Lippincott Williams & Wilkins.

Salvo, S. G. (2007). Massage Therapy: Principles and Practice. St. Louis, Saunders Elsevier.

Sharkey, J. (2007). The Concise Book of Neuromuscular Therapy: A Trigger Point Manual. Berkeley, CA, North Atlantic Books.

Speer, K. P., Ed. (2005). Injury Prevention and Rehabilitation for Active Older Adults. Champaign, Il, Human Kinetics.

Starkey, C. (2004). Therapeutic Modalities. Philadelphia, F.A. Davis.

Starkey, C., G. Johnson, et al., Eds. (2006). Athletic Training and Sports Medicine Sudbury, Mass, Jones and Bartlett.

Stricker, L. A. (2007). Pilates for the Outdoor Athlete. Golden, CO, Fulcrum.

Taylor, A. W. and M. J. Johnson (2008). Physiology of Exercise and Healthy Aging. Champaign, Il, Human Kinetics.

Thibodeau, G. A. and K. T. Patton (2005). The Human Body in Health & Disease. St. Louis, Mosby.

Thorp, C. (2008). Pharmacology for the Health Care Professions. Hoboken, N.J., Wiley.

Travell, J. G. and D. G. Simons (1983). Myofascial Pain and Dysfunction. The Trigger Point Manual. The Upper Extremities. Baltimore, Williams & Wilkins.

Travell, J. G. and D. G. Simons (1992). Myofascial Pain and Dysfunction. The Trigger Point Manual. The Lower Extremities. Baltimore, Williams & Wilkins.

Vargas, L. G. (2004). Aquatic Therapy: Interventions and Applications. Ravensdale, WA, Idyll Arbor.


Walker, B. (2007). The Anatomy of Sports Injuries. Berkeley, CA, North Atlantic Books.

Watson, T., Ed. (2008). Electrotherapy: Evidence‐Based Practice. New York, Churchill Livingstone.

Weiselfish‐Giammatteo, S. (2003). Integrative Manual Therapy for the Upper and Lower Extremities. volume III. Berkeley, CA, North Atlantic Books.

Werner, R. A. (2009). A Massage Therapist's Guide to Pathology. Baltimore, Wolters Kluwer/Lippincott Williams & Wilkins.

Wilmore, J. H., D. L. Costill, et al. (2008). Physiology of Sport and Exercise. Champaign, IL, Human Kinetics.

Wolinsky, I. and J. A. Driskell, Eds. (2008). Sports Nutrition: Energy Metabolism and Exercise. Boca Raton, FL, CRC Press.

Zatsiorsky, V. M. and W. J. Kraemer (2006). Science and Practice of Strength Training. Champaign, IL, Human Kinetics.

Domain 5

Akobeng, A. (2005). "Principles of evidence based medicine." Archives of Disease in Childhood 90: 837‐840.

Andress, A. (2003). Saunders Textbook of Medical Office Management. St. Louis, Elsevier Science.

Appenzeller, H. (2005). Risk Management in Sport: Issues and Strategies Durham, NC, Carolina Academic Press.

Association, N. A. T. (2005). "NATA Code of Ethics." Retrieved May 12, 2008, from http://www.nata.org/codeofethics/code_of_ethics.pdf.

Bartkowiak, B. A. (2004). "Searching for evidence‐based medicine in the literature: Part 1: The start." Clin Med Res 2(4): 254‐255.

Bartkowiak, B. A. (2005). "Searching for evidence‐based medicine in the literature Part 2: Resources." Clin Med Res 3(1): 39‐40.

Bartkowiak, B. A. (2005). "Searching for evidence‐based medicine in the literature Part 3: Assessment." Clin Med Res 3(2): 113‐115.

Berry, D. C., M. G. Miller, et al. (2007) An analysis of the professional journal reading habits and attitudes of certified athletic trainers. International Council for Health Physical Education Reaction, Sport and Dance Research Journal 2, 12‐18.

Board of Certification (2006). BOC Standards of Professional Practice. http://www.bocatc.org/.

Cardarelli, R., R. F. Virgilio, et al. (2007). "Evidence‐based medicine, Part 2. An introduction to critical appraisal of articles on therapy." J Am Osteopathic Assoc 107(8): 299‐303.

Cuppett, M. M. (2001). "Self‐perceived continuing education needs of certified athletic trainers." J Athl Training 36: 388‐395.

Finocchio, L. J., C. M. Dower, et al. (1995). Reforming health care workforce regulation: Policy considerations for the 21st century, Pew Health Professions Commission.

Governement, U. S. (2008). "U.S. Equal Employmeny Opportunity Commission." Retrieved May 31, 2008, from http://www.eeoc.gov/.

Grayson, E. (1999). Ethics, Injuries and the Law in Sports Medicine. Oxford, Butterworth‐Heinemann.

Hannam, S. (2000). Professional Behavior in Athletic Training. Thorofare, NJ, Slack Publishers.


Kettenbach, G. (2009). Writing SOAP Notes: With Patient/Client Management Formats. Philadelphia, F.A. Davis Company.

Kettenbach, G. (2009). Writing SOAP Notes: With Patient/Client Management Formats. Philadelphia, F.A. Davis Company.

Konin, J. G. and M. Frederick (2005). Documentation for Athletic Training. Thorofare, SLACK Incorporated.

Labor, D. o. (2008). "Employment Standards Administration." Retrieved May 12, 2008, from http://www.dol.gov/esa/.

Labor, D. o. (2008). "Occupational Safety & Health Administration." Retrieved May 12, 2008, from http://www.osha.gov/.

MacAuley, D. and T. M. Best, Eds. (2007). Evidence‐Based Sports Medicine. Malden, Mass, Blackwell.

NATA (1995). "Blood‐Borne Pathogens Guidelines for Athletic Trainers." J Athl Training 30(3): 203‐204.

NATA (2005). "Official Statement on Community‐Acquired MRSA Infections (CA‐MRSA)." J Athl Training.

NATA (2007). "Recommendations and guidelines for appropriate medical coverage of intercollegiate athletics." Retrieved May 31, 2008, from http://www.nata.org/statements/support/AMCIARecsandGuides.pdf.

NATA, J. Almquist, et al. (2004). "Appropriate medical care for secondary school‐age athletes communication." Retrieved May 31, 2008, from http://www.nata.org/statements/support/secondary_school_medcarecommunication.pdf.



OSHA (1991). "Bloodborne Pathogens 1910.1030." from http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051.

OSHA (1991). Occupational Exposure to Bloodborne Pathogens; final rule. U. S. D. o. Labor. 56: 64003‐64182.

Pitney, W. A. (1998). "Continuing education in athletic training: An alternative approach based on adult learning theory." J Athl Training 33: 72‐76.

Prentice, W. E. (2009). Arnheim's Principles of Athletic Training. Boston, McGraw‐Hill Higher Education.

Prentice, W. E. (2009). Arnheim's Principles of Athletic Training. Boston, McGraw‐Hill Higher Education.



Richmond, T. and D. Powers (2004). Business Fundamentals for the Rehabilitation Professional. Thorofare, SLACK Incorporated.

RSM McGladrey Inc. (2008). Mandated Benefits: 2008 Compliance Guide. New York, Aspen Publishers.

Steves, R. and J. M. Hootman (2004). "Evidence‐based medicine: What is it and how does it apply to Athletic Training?" J Athl Training 39(1): 83‐87.

Virgilio, R. F., A. L. Chiapa, et al. (2007). "Evidence‐based medicine, Part 1. An introduction to creating an answerable question and searching the evidence." J Am Osteopath Assoc 107(7): 295‐297.


Walker, S. E., W. E. Pitney, et al. (2008) An exploration of athletic trainers’ perceptions of the continuing education process. Internet Journal of Allied Health Sciences and Practice 6.

Weidner, T. G. (1994). "Athletic training continuing education needs assessment: Pilot study." J Athl Training 29: 67‐69.

Winterstein, A. (2009). Athletic Training Student Primer: A Foundation for Success. Thorofare, NJ, Slack Incorporated.


Appendix B: Average ratings of writing difficulty for 15 BOC item writers, September 2008

Domain Task Average

Prevention Educate the appropriate individual(s) about risks associated with participation and specific activities using effective communication techniques to minimize the risk of injury and illness.

2.10

Interpret pre‐participation and other relevant screening information in accordance with accepted guidelines to minimize the risk of injury and illness.

1.53

Instruct the appropriate individual(s) about standard protective equipment using effective communication techniques to minimize the risk of injury and illness.

1.73

Apply appropriate prophylactic/protective measures using commercial products or custom‐made devices to minimize the risk of injury and illness.

1.87

Identify safety hazards associated with activities, activity areas, and equipment by following accepted procedures and guidelines in order to make appropriate recommendations and to minimize the risk of injury and illness.

1.53

Maintain clinical and treatment areas by complying with safety and sanitation standards to minimize the risk of injury and illness.

1.67

Monitor participants and environmental conditions by following accepted guidelines to promote safe participation.

1.43

Facilitate physical conditioning by designing and implementing appropriate programs to minimize the risk of injury and illness.

1.60

Facilitate healthy lifestyle behaviors using effective education, communication, and interventions to reduce the risk of injury and illness and promote wellness.

2.13

Recognition, Evaluation, and Assessment

Obtain a history through observation, interview, and/or review of relevant records to assess current or potential injury, illness, or condition.

1.60

Inspect the involved area(s) visually to assess the injury, illness, or health‐related condition.

1.80

Palpate the involved area(s) using standard techniques to assess the injury, illness, or health‐related condition.

1.80

Perform specific tests in accordance with accepted procedures to assess the injury, illness, or health‐related condition.

1.60

Formulate a clinical impression by interpreting the signs, symptoms, and predisposing factors of the injury, illness, or condition to determine the appropriate course of action.

1.40

Educate the appropriate individual(s) regarding the assessment by communicating information about the current or potential injury, illness, or health‐related condition to encourage compliance with recommended care.

1.87

Share assessment findings with other health care professionals using effective means of communication to coordinate appropriate care.

1.93


Domain Task Average

Immediate Care

Employ life‐saving techniques through the use of standard emergency procedures in order to reduce morbidity and the incidence of mortality.

1.55

Prevent exacerbation of non‐life‐threatening condition(s) through the use of standard procedures in order to reduce morbidity.

1.60

Facilitate the timely transfer of care for conditions beyond the scope of practice of the athletic trainer by implementing appropriate referral strategies to stabilize and/or prevent exacerbation of the condition(s).

1.80

Direct the appropriate individual(s) in standard immediate care procedures using formal and informal methods to facilitate immediate care.

1.53

Execute the established emergency action plan using effective communication and administrative practices to facilitate efficient immediate care.

1.73

Treatment, Rehabilitation, and Reconditioning

Administer therapeutic and conditioning exercise(s) using standard techniques and procedures in order to facilitate recovery 1.60

Administer therapeutic modalities using standard techniques and procedures in order to facilitate recovery

1.47

Apply braces, splints, or assistive devices in accordance with appropriate standards and practices in order to facilitate recovery, function, and/or performance.

1.87

Administer treatment for general illness and/or conditions using standard techniques and procedures to facilitate recovery, function, and/or performance.

2.00

Reassess the status of injuries, illnesses, and/or conditions using standard techniques and documentation strategies in order to determine appropriate treatment, rehabilitation, and/or reconditioning and to evaluate readiness to return to a desired level of activity.

1.67

Educate the appropriate individual(s) in the treatment, rehabilitation, and reconditioning of injuries, illnesses, and/or conditions using applicable methods and materials to facilitate recovery, function, and/or performance.

1.73

Provide guidance and/or counseling for the appropriate individual(s) in the treatment, rehabilitation, and reconditioning of injuries, illnesses, and/or conditions through communication to facilitate recovery, function, and/or performance.

2.07

Organization and Administration

Establish action plans for response to injury or illness using available resources to provide the required range of health care services for individuals, athletic activities, and events.

2.40

Establish policies and procedures for the delivery of health care services following accepted guidelines to promote safe participation, timely care, and legal compliance.

2.53


Domain Task Average

Establish policies and procedures for the management of health care facilities and activity areas by referring to accepted guidelines, standards, and regulations to promote safety and legal compliance.

2.47

Manage human and fiscal resources by utilizing appropriate leadership, organization, and management techniques to provide efficient and effective health care services.

2.73

Maintain records using an appropriate system to document services rendered, provide for continuity of care, facilitate communication, and meet legal standards.

2.33

Develop professional relationships with appropriate individuals and entities by applying effective communication techniques to enhance the delivery of health care.

2.60

Professional Responsibility

Demonstrate appropriate professional conduct by complying with applicable standards and maintaining continuing competence to provide quality athletic training services.

2.10

Adhere to statutory and regulatory provisions and other legal responsibilities relating to the practice of athletic training by maintaining an understanding of these provisions and responsibilities in order to contribute to the safety and welfare of the public.

2.40

Educate appropriate individuals and entities about the role and standards of practice of the athletic trainer through informal and formal means to improve the ability of those individuals and entities to make informed decisions.

2.07


Appendix C: Attendees of the October 2008 subject matter panel meeting

First Name Last Name Affiliation/Organization State Practice Setting

David Berry Weber State University UT Univ/College Nancy Burke Fairfax County Police Department VA Law Enforcement Bryan Diekmann Steadman Hawkins Clinic CO Physician Extender Anita Eisenhauer Orthopaedic and Sports Medicine

Center CT Clinic/PE/Pro softball

Peggy Houglum Duquesne University PA Univ/College Kim Jenckes AthletiCo Physical Therapy/ Illinois

Cheer co. All‐Star Cheer IL Corp/AT

Chad Kinart ESPN Sports Medicine/ Board of Certification, Inc.

NE X Games

Mary Kirkland KSC Rehab Works/The Bionetics Corp. FL NASAJan Lauer Tri‐Rehab, Inc. MI Clinic/Hosp Linda Mazzoli Cooper Bone and Joint Institute;

Cooper Univ. Hosp. PA PR

Steve McCauley Wynn Las Vegas NV Corp Health Svcs Ralph Reiff St. Vincent Sports Performance IN NASCAR Edugene Schafer ARC Athletics NY Corp/Owner Christine Schneider ProActive Sports Medicine CT Clinic/pro Edward Sedory United States Marine Corps VA DEAAlfred Shuford AIOSM, Inc. NCDiana Settles

Strock Navy and Marine Corps Public Health Center

NC Corp/Owner

Samantha Sweet Grand River Hospital CO Clinic/HS Outreach Clint Thompson ATC Retired WA ChairNina Walker University of North Carolina at Chapel

Hill NC Univ/College

Kerry Waple Nationwide Childrens' Hospital Sports Medicine

OH Clinic/Hosp

Chris Watts Steadman‐|Hawkins Clinic CO Physician Extender Sean Willford Texas Christian University TX Education

Stephen Johnson FACILITATOR

Denise Fandel BOC ‐ Observer


Appendix D: Background of the October 2008 subject matter panel meeting

Age Sex Race Years in Field

What are you Doing Now?

Place of Work Highest Ed. Degrees/Certs Held

25‐30 Female White 3‐5 Working full time Large Corporation, Competitive all‐star cheerleading, U.S. youth soccer, youth football, field inventory specialist for PDMA

Bachelor's B.S. Athletic Training

25‐30 Male Multi‐racial 6‐10 Working full time Federal Government

Master's B.S. Athletic Training, Med Athletic training, Emergency Medical Technician, 1st aid/AED/CPR/ Instructor

25‐30 Female White 3‐5 Working full time High school, currently but when applied I worked with rec soccer teams

Master's

25‐30 Male White 6‐10 Working full time Small Business Master's ATC, OTC

31‐35 Male White 6‐10 Working full time Educational Institution, Small Business

Master's Msed, ATC, First Aid/CPR

31‐35 Male White 6‐10 Working part time Large Corporation Master's ATC, MS

31‐35 Female Black 6‐10 Working full time Educational Institution

Master's ATC, CSCS

36‐40 Female White 15+ Working full time Federal Government, Department of Defense

Master's ACSM Group Exercise Leader, ACE Group Exercise Leader, Certified Health Promotion Director through Cooper Institute for Aerobics Research. ATC, Master of Arts in T..‐ Physical Athletic Training, Bachelor in Exercise Science...

36‐40 Male White 15+ Working full time Educational Institution

Doctorate EMT‐B, ATC

36‐40 Female White 15+ Multiple jobs part time and contract

Educational Institution, State or Local Government, Small Business, Self Employed ‐ Contracting at Services

Bachelor's

36‐40 Male White 15+ Working full time Educational Institution

Master's

36‐40 Female White 15+ Working full time Small Business Master's MAT, ATC, LAT, ICATRIC, CSFA, International Council Aquatic Therapy


Age Sex Race Years in Field

What are you Doing Now?

Place of Work Highest Ed. Degrees/Certs Held

Rehab Institute Certified, Certified Specialist in Functional Assessment

41‐50 Female White 15+ Working full time Federal Government

Master's MS, ATC, LAT, CSCS

41‐50 Female White 15+ Working full time Educational Institution, Hospital sports medicine program

Master's NSCA‐certified strength and conditioning specialist, AHA‐CPR instructor

41‐50 Male White 11‐15 Working full time Large Corporation Bachelor's LAT, ATC, CSCS

41‐50 Male White 15+ Working full time Small Business Master's CSCS

41‐50 Male White 15+ Working full time Large Corporation Master's ATC, M.Ed.

41‐50 Female White 15+ Working full time Small Business Master's NCSA‐CSCS, Teaching Cert. K‐12 P.E. (Missouri)

41‐50 Female White 15+ Working full time Large Corporation, Hospital

Master's MS Injury Prevention, BS Student Design; Athletic Training, AS ‐ Physical Therapy Assistant, Certificate ‐ Performance Enhancement Specialty; NASM

41‐50 Male Black 15+ Working full time Large Corporation, Educational Institution

Master's CEAS, LAT, STS, ATC, M. Ed. Education/Athletic Administration, BS ‐ Health and Physical Education

51‐60 Female White 15+ Working full time State or Local Government

Master's Collegiate professional certified, MS., BS.

51‐60 Female White 15+ Working full time Educational Institution

Doctorate ATC, PhD, PT

60+ Male White 15+ Retired Have worked ‐ collegiate

Master's ATC


Appendix E: Workbook used for the October 2008 subject matter panel meeting


Appendix F: Survey tool used for BOC athletic trainer role delineation study, March‐April 2009


Appendix G: E‐mail requests sent to potential survey respondents

First E‐mail Request ********************************* Dear NAME, You have been selected to participate in a survey to review and provide input on updates to the Board of Certification (BOC) role delineation study. This study defines the roles and responsibilities of an entry‐level athletic trainer certified by the BOC and serves as the blueprint for the certification exam and continuing education programs. As part of the study, a panel of BOC certified athletic trainers from a variety of backgrounds identified updates and revisions to the domains and tasks. The purpose of this survey is to solicit feedback from certified athletic trainers regarding these updates. This process is a requirement of the criteria and policies for competency assessment established through the National Commission for Certifying Agencies (NCCA) test development standards that the BOC follows. Completion of the survey should take approximately 30 minutes. You do not need to complete the survey at one sitting, but can return multiple times. Your participation in this effort is invaluable in defining the profession of an athletic trainer. Once you have completed the survey, you will be entered into a drawing to win a Garman Nuvi 350 GPS. One participant will be selected at random to receive this wonderful prize, courtesy of the BOC. Only completed surveys will be eligible, and your identifying information will NOT be tied to your survey answers. A response is appreciated by 23:59 EST April 5th, 2009. Please make sure to complete the survey with your thoughtful and complete answers by the deadline noted above to be entered in the drawing. To begin the survey, please click here: http://www.castleworldwide.com/BOCCAT/Secure/SecureHome.aspx Please use the following username/password combination to gain access to the survey: Username: [email protected] Password: password123 If you have any questions about this survey, please send an e‐mail to [email protected]. Thank you for your participation. Bernadette Olsen President BOC *********************************


Follow‐up E‐mail Requests to Participate ********************************* Dear NAME, Recently you received an e‐mail requesting your participation in a survey for the Board of Certification (BOC) role delineation survey. We would like to encourage you to complete the survey by 23:59 EST 15 April, 2009. Survey completion should take approximately 30 minutes and your responses will be confidential and shared only in aggregate with BOC. Your feedback is very important in helping establish the entry‐level blueprint for the BOC certification examination. Remember that your complete survey not only supports the profession but also enters you into the drawing to win a Garman Nuvi 350 GPS. To complete the survey, please log in at this web site: http://www.castleworldwide.com/BOCCAT/Secure/SecureHome.aspx Please use the following username/password combination to gain access to the survey: Username: [email protected] Password: password123 If you have any questions about this survey, please send an e‐mail to [email protected]. Thank you for your consideration. Sincerely, Bernadette Olsen President BOC *********************************


Appendix H: Number and percent of persons from each U.S. state for members certified 3 to 7 years, members sent requests, and members who responded to the validation survey, April 2009

Members Requests Responses

N % N % N %

None listed 1 0.0 1 0.0AE 2 0.0 AK 5 0.1 4 0.1AL 141 1.9 102 2.0 19 1.6AP 1 0.0 1 0.0AR 60 0.8 48 1.0 10 0.9AZ 153 2.1 109 2.2 24 2.1CA 509 7.0 357 7.1 68 5.9CO 167 2.3 119 2.4 31 2.7CT 116 1.6 93 1.9 20 1.7DC 6 0.1 4 0.1DE 35 0.5 23 0.5 6 0.5FL 402 5.5 282 5.6 44 3.8GA 220 3.0 148 3.0 31 2.7HI 37 0.5 25 0.5 8 0.7IA 137 1.9 98 2.0 26 2.3ID 43 0.6 30 0.6 9 0.8IL 400 5.5 266 5.3 61 5.3IN 194 2.7 128 2.6 37 3.2KS 96 1.3 66 1.3 20 1.7KY 91 1.3 61 1.2 23 2.0LA 68 0.9 42 0.8 5 0.4MA 177 2.4 123 2.5 27 2.3MD 115 1.6 73 1.5 23 2.0ME 53 0.7 36 0.7 5 0.4MI 218 3.0 157 3.1 32 2.8MN 188 2.6 132 2.6 32 2.8MO 140 1.9 95 1.9 17 1.5MS 60 0.8 41 0.8 10 0.9MT 25 0.3 18 0.4 3 0.3NC 262 3.6 181 3.6 52 4.5ND 25 0.3 17 0.3 4 0.3NE 85 1.2 56 1.1 14 1.2NH 53 0.7 41 0.8 12 1.0NJ 166 2.3 110 2.2 20 1.7NM 42 0.6 30 0.6 10 0.9NV 42 0.6 33 0.7 5 0.4NY 305 4.2 210 4.2 39 3.4OH 398 5.5 268 5.4 64 5.6OK 80 1.1 61 1.2 17 1.5OR 101 1.4 70 1.4 23 2.0PA 429 5.9 309 6.2 78 6.8RI 25 0.3 18 0.4 5 0.4SC 145 2.0 101 2.0 20 1.7


Members Requests Responses

N % N % N %

SD 40 0.6 20 0.4 2 0.2TN 160 2.2 100 2.0 19 1.6TX 297 4.1 199 4.0 60 5.2UT 62 0.9 39 0.8 6 0.5VA 272 3.7 176 3.5 44 3.8VT 28 0.4 26 0.5 6 0.5WA 141 1.9 101 2.0 17 1.5WI 176 2.4 116 2.3 33 2.9WV 53 0.7 34 0.7 11 1.0WY 8 0.1 6 0.1Total 7255 100.0 5003 100.0 1152 100.0


Appendix I: Criticality statistics for BOC domains and tasks

Mean Skewness Kurtosis

N Statistic Std. Error Std.

Deviation Statistic Std. Error Statistic Std. Error

Criticality 01 1123 2.83 .02 .79 ‐.29 .07 ‐.32 .15

02 1122 3.19 .02 .75 ‐.79 .07 .55 .15

03 1122 3.73 .02 .65 ‐2.78 .07 7.72 .15

04 1120 2.81 .02 .69 ‐.32 .07 .15 .15

05 1116 2.28 .02 .82 .28 .07 ‐.39 .15

0101 1037 2.60 .02 .77 ‐.11 .08 ‐.34 .15

0102 1037 2.89 .03 .82 ‐.35 .08 ‐.45 .15

0103 1036 2.57 .02 .74 .06 .08 ‐.34 .15

0104 1028 2.65 .02 .75 ‐.03 .08 ‐.36 .15

0105 1026 3.12 .02 .80 ‐.63 .08 ‐.11 .15

0106 1024 2.40 .02 .69 .12 .08 ‐.18 .15

0107 1021 2.06 .02 .68 .33 .08 .21 .15

0201 997 2.89 .03 .85 ‐.47 .08 ‐.34 .15

0202 997 2.96 .03 .83 ‐.52 .08 ‐.24 .15

0203 997 3.09 .02 .78 ‐.59 .08 ‐.04 .15

0204 994 3.19 .02 .78 ‐.87 .08 .55 .15

0205 994 2.81 .03 .80 ‐.35 .08 ‐.26 .15

0301 988 2.73 .03 .84 ‐.26 .08 ‐.49 .16

0302 987 3.76 .02 .62 ‐2.86 .08 8.05 .16

0303 988 3.31 .03 .82 ‐1.07 .08 .53 .16

0304 987 3.34 .03 .82 ‐1.18 .08 .85 .16

0401 979 2.68 .02 .69 ‐.07 .08 ‐.21 .16

0402 980 2.83 .03 .80 ‐.15 .08 ‐.60 .16

0403 980 2.61 .02 .73 .00 .08 ‐.31 .16

0404 979 2.85 .02 .72 ‐.35 .08 .09 .16

0405 972 2.84 .02 .76 ‐.35 .08 ‐.10 .16

0406 971 2.45 .03 .78 ‐.05 .08 ‐.44 .16

0501 975 1.57 .02 .69 .98 .08 .38 .16

0502 975 1.40 .02 .64 1.50 .08 1.64 .16

0503 975 2.25 .03 .93 .29 .08 ‐.78 .16

0504 972 2.72 .03 .95 ‐.22 .08 ‐.90 .16

0505 973 2.43 .03 .93 .09 .08 ‐.86 .16

0506 973 2.43 .03 .86 .02 .08 ‐.65 .16

Critical values: Domain Criticality (2.34 < t99CI < 3.60, df = 4); Task Criticality (2.46 < t99CI < 2.93, df = 27).


Appendix J: Frequency statistics for BOC domains and tasks

Mean Skewness Kurtosis

N Statistic Std. Error Std.

Deviation Statistic Std. Error Statistic Std. Error

Frequency 01 1123 3.31 .02 .70 ‐.69 .07 ‐.02 .15

02 1122 3.68 .02 .56 ‐1.80 .07 3.34 .15

03 1121 3.02 .03 .88 ‐.48 .07 ‐.66 .15

04 1118 3.42 .02 .65 ‐.76 .07 ‐.09 .15

05 1115 2.87 .02 .83 ‐.18 .07 ‐.74 .15

0101 1037 2.85 .02 .78 ‐.11 .08 ‐.64 .15

0102 1037 2.58 .03 .84 ‐.06 .08 ‐.60 .15

0103 1036 2.50 .03 .83 .15 .08 ‐.55 .15

0104 1027 2.98 .02 .80 ‐.41 .08 ‐.36 .15

0105 1025 2.75 .03 .88 ‐.24 .08 ‐.68 .15

0106 1023 2.41 .03 .88 .16 .08 ‐.68 .15

0107 1019 2.21 .03 .81 .38 .08 ‐.25 .15

0201 997 3.46 .02 .71 ‐1.24 .08 1.23 .15

0202 997 3.63 .02 .60 ‐1.66 .08 2.89 .15

0203 997 3.63 .02 .60 ‐1.63 .08 2.70 .15

0204 994 3.57 .02 .66 ‐1.59 .08 2.44 .15

0205 994 3.45 .02 .68 ‐1.10 .08 .95 .15

0301 988 3.10 .03 .80 ‐.56 .08 ‐.24 .16

0302 987 2.69 .03 .97 ‐.13 .08 ‐.99 .16

0303 987 2.66 .03 .89 ‐.13 .08 ‐.74 .16

0304 986 2.47 .03 .93 .08 .08 ‐.86 .16

0401 979 3.29 .02 .72 ‐.75 .08 .10 .16

0402 980 3.14 .03 .88 ‐.77 .08 ‐.23 .16

0403 980 2.85 .03 .83 ‐.13 .08 ‐.79 .16

0404 979 3.24 .02 .72 ‐.64 .08 .00 .16

0405 972 3.28 .02 .70 ‐.64 .08 ‐.11 .16

0406 971 2.75 .03 .79 ‐.03 .08 ‐.60 .16

0501 975 1.95 .03 .85 .57 .08 ‐.41 .16

0502 975 1.69 .03 .78 .97 .08 .43 .16

0503 975 3.17 .03 .85 ‐.77 .08 ‐.14 .16

0504 972 2.45 .03 .90 .19 .08 ‐.72 .16

0505 973 2.56 .03 .95 .01 .08 ‐.94 .16

0506 973 1.87 .03 .80 .69 .08 .00 .16

Critical values: Domain Frequency (2.53 < t99CI < 3.99, df = 4); Task Frequency (2.58 < t99CI < 3.08, df = 27).


Appendix K: Correlations for ratings of frequency and criticality for five domains

Domain 1 Criticality





Domain 1 Freq.

Domain 2 Freq.

Domain 3 Freq.

Domain 4 Freq.

Domain 5 Freq.


Pearson r .331**

.085**

.117** .048 .144

**

Sig. (2‐tailed) .000 .004 .000 .112 .000

N 1123 1122 1121 1118 1115


Pearson r .440** .106

**.297

**.151

** .133

**.134

**

Sig. (2‐tailed) .000 .000 .000 .000 .000 .000

N 1122 1122 1122 1121 1118 1115


Pearson r .417** .533

** .059

*.172

**.006 .062

*‐.001

Sig. (2‐tailed) .000 .000 .046 .000 .846 .037 .978

N 1122 1122 1122 1122 1121 1118 1115


Pearson r .407** .469

** .424

**.096

**.176

**.197

** .294

**.174

**

Sig. (2‐tailed) .000 .000 .000 .001 .000 .000 .000 .000

N 1120 1120 1120 1120 1120 1120 1118 1114


Pearson r .432** .380

** .278

**.463

**.161

**.105

**.250

** .116

**.363

**

Sig. (2‐tailed) .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1116 1116 1116 1114 1116 1116 1115 1112 1115

Domain 1 Freq.

Pearson r .331** .106

** .059

*.096

**.161

**

Sig. (2‐tailed) .000 .000 .046 .001 .000

N 1123 1122 1122 1120 1116

Domain 2 Freq.

Pearson r .085** .297

** .172

**.176

**.105

**.237

**

Sig. (2‐tailed) .004 .000 .000 .000 .000 .000

N 1122 1122 1122 1120 1116 1122

Domain 3 Freq.

Pearson r .117** .151

** .006 .197

**.250

**.138

**.234

**

Sig. (2‐tailed) .000 .000 .846 .000 .000 .000 .000

N 1121 1121 1121 1120 1115 1121 1121

Domain 4 Freq.

Pearson r .048 .133** .062

*.294

**.116

**.132

**.261

**.138

**

Sig. (2‐tailed) .112 .000 .037 .000 .000 .000 .000 .000

N 1118 1118 1118 1118 1112 1118 1118 1118

Domain 5 Freq.

Pearson r .144** .134

** ‐.001 .174

**.363

**.242

**.180

**.221

** .244

**

Sig. (2‐tailed) .000 .000 .978 .000 .000 .000 .000 .000 .000

N 1115 1115 1115 1114 1115 1115 1115 1115 1112

**. Correlation is significant at the 0.01 level (2‐tailed). *. Correlation is significant at the 0.05 level (2‐tailed).


Appendix L: Correlations for ratings of frequency and criticality for 28 tasks

Criticality Criticality 0101 0102 0103 0104 0105 0106 0107 0201 0202 0203 0204 0205 0301 0302

0101 Pearson r 1 .494 .525 .469 .387 .414 .447 .421 .428 .419 .390 .468 .348 .312

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1037 1037 1034 1026 1024 1022 1019 993 993 993 990 990 985 984

0102 Pearson r .494 1 .484 .448 .440 .335 .362 .504 .419 .432 .422 .423 .380 .376

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1037 1037 1034 1026 1024 1022 1019 993 993 993 990 990 985 984

0103 Pearson r .525 0 1.000 .468 .424 .413 .442 .411 .400 .414 .374 .446 .365 .324

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1034 1034 1036 1028 1026 1024 1021 994 994 994 991 991 986 985

0104 Pearson r .469 0 .468 1.000 .462 .466 .426 .438 .405 .422 .384 .451 .382 .345

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1026 1026 1028 1028 1026 1024 1021 988 988 988 987 987 981 980

0105 Pearson r .387 0 .424 .462 1.000 .361 .360 .418 .365 .350 .374 .376 .362 .439

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1024 1024 1026 1026 1026 1023 1020 988 988 988 987 987 981 980

0106 Pearson r .414 0 .413 .466 .361 1.000 .564 .381 .358 .351 .362 .359 .340 .292

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1022 1022 1024 1024 1023 1024 1021 987 987 987 986 986 980 979

0107 Pearson r .447 0 .442 .426 .360 .564 1.000 .381 .335 .312 .271 .413 .351 .206

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1019 1019 1021 1021 1020 1021 1021 987 987 987 986 986 980 979

0201 Pearson r .421 1 .411 .438 .418 .381 .381 1.000 .689 .616 .557 .568 .519 .400

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0202 Pearson r .428 0 .400 .405 .365 .358 .335 .689 1.000 .767 .632 .594 .490 .406

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0203 Pearson r .419 0 .414 .422 .350 .351 .312 .616 .767 1.000 .679 .573 .492 .455

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0204 Pearson r .390 0 .374 .384 .374 .362 .271 .557 .632 .679 1.000 .587 .470 .463

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 990 990 991 987 987 986 986 994 994 994 994 994 987 986

0205 Pearson r .468 0 .446 .451 .376 .359 .413 .568 .594 .573 .587 1.000 .569 .417

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 990 990 991 987 987 986 986 994 994 994 994 994 987 986

0301 Pearson r .348 0 .365 .382 .362 .340 .351 .519 .490 .492 .470 .569 1.000 .387

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 985 985 986 981 981 980 980 988 988 988 987 987 988 987

0302 Pearson r .312 0 .324 .345 .439 .292 .206 .400 .406 .455 .463 .417 .387 1.000

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 984 984 985 980 980 979 979 987 987 987 986 986 987 987

0303 Pearson r .334 0 .356 .350 .365 .321 .268 .410 .397 .430 .432 .437 .482 .589

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 984 984 985 980 980 979 979 988 988 988 987 987 987 987

0304 Pearson r .357 0 .354 .347 .412 .313 .318 .452 .449 .461 .444 .466 .465 .571

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 983 983 984 980 980 979 979 987 987 987 987 987 986 986

0401 Pearson r .323 0 .380 .423 .296 .449 .330 .389 .437 .481 .431 .433 .392 .318

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000



N 978 978 978 975 975 975 975 979 979 979 978 978 979 979

0402 Pearson r .213 0 .251 .413 .291 .353 .222 .283 .331 .386 .346 .355 .331 .319

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 978 978 979 976 976 976 976 980 980 980 979 979 980 980

0403 Pearson r .333 0 .392 .424 .332 .427 .389 .413 .472 .485 .426 .471 .467 .352

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 978 978 979 976 976 976 976 980 980 980 979 979 980 980

0404 Pearson r .380 0 .385 .473 .346 .441 .363 .454 .507 .532 .466 .495 .444 .404

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 977 977 978 975 975 975 975 979 979 979 978 978 979 979

0405 Pearson r .373 0 .368 .431 .362 .415 .346 .462 .506 .514 .514 .498 .448 .415

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 970 970 971 969 969 969 969 972 972 972 971 971 972 972

0406 Pearson r .388 0 .397 .376 .302 .391 .395 .462 .499 .481 .449 .514 .508 .326

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 969 969 970 968 968 968 968 971 971 971 970 970 971 971

0501 Pearson r .365 0 .341 .309 .229 .323 .356 .327 .298 .283 .246 .354 .350 .112

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0502 Pearson r .313 0 .295 .267 .218 .287 .392 .286 .243 .228 .164 .273 .259 .097

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .002

N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0503 Pearson r .343 0 .354 .367 .314 .321 .341 .422 .376 .351 .314 .402 .361 .237

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0504 Pearson r .331 0 .359 .313 .393 .280 .293 .407 .349 .386 .317 .360 .386 .364

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 969 969 970 968 968 968 968 972 972 972 972 972 971 971

0505 Pearson r .364 0 .362 .403 .376 .313 .342 .447 .381 .377 .355 .452 .428 .312

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 970 970 971 969 969 969 969 973 973 973 973 973 972 972

0506 Pearson r .364 0 .346 .301 .381 .281 .355 .364 .343 .356 .358 .392 .405 .356

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 970 970 971 969 969 969 969 973 973 973 973 973 972 972


0101 Pearson r .334 .357 .323 0 .333 .380 .373 .388 .365 .313 .343 .331 .364 .364

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 984 983 978 978 978 977 970 969 972 972 972 969 970 970

0102 Pearson r .388 .429 .325 0 .350 .364 .350 .366 .315 .249 .367 .411 .392 .400

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 984 983 978 978 978 977 970 969 972 972 972 969 970 970

0103 Pearson r .356 .354 .380 0 .392 .385 .368 .397 .341 .295 .354 .359 .362 .346

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 985 984 978 979 979 978 971 970 973 973 973 970 971 971

0104 Pearson r .350 .347 .423 0 .424 .473 .431 .376 .309 .267 .367 .313 .403 .301

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 980 980 975 976 976 975 969 968 970 970 970 968 969 969

0105 Pearson r .365 .412 .296 0 .332 .346 .362 .302 .229 .218 .314 .393 .376 .381

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000



N 980 980 975 976 976 975 969 968 970 970 970 968 969 969

0106 Pearson r .321 .313 .449 0 .427 .441 .415 .391 .323 .287 .321 .280 .313 .281

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 979 979 975 976 976 975 969 968 970 970 970 968 969 969

0107 Pearson r .268 .318 .330 0 .389 .363 .346 .395 .356 .392 .341 .293 .342 .355

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 979 979 975 976 976 975 969 968 970 970 970 968 969 969

0201 Pearson r .410 .452 .389 0 .413 .454 .462 .462 .327 .286 .422 .407 .447 .364

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 988 987 979 980 980 979 972 971 975 975 975 972 973 973

0202 Pearson r .397 .449 .437 0 .472 .507 .506 .499 .298 .243 .376 .349 .381 .343

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 988 987 979 980 980 979 972 971 975 975 975 972 973 973

0203 Pearson r .430 .461 .481 0 .485 .532 .514 .481 .283 .228 .351 .386 .377 .356

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 988 987 979 980 980 979 972 971 975 975 975 972 973 973

0204 Pearson r .432 .444 .431 0 .426 .466 .514 .449 .246 .164 .314 .317 .355 .358

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 987 987 978 979 979 978 971 970 975 975 975 972 973 973

0205 Pearson r .437 .466 .433 0 .471 .495 .498 .514 .354 .273 .402 .360 .452 .392

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 987 987 978 979 979 978 971 970 975 975 975 972 973 973

0301 Pearson r .482 .465 .392 0 .467 .444 .448 .508 .350 .259 .361 .386 .428 .405

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 987 986 979 980 980 979 972 971 974 974 974 971 972 972

0302 Pearson r .589 .571 .318 0 .352 .404 .415 .326 .112 .097 .237 .364 .312 .356

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .002 .000 .000 .000 .000

N 987 986 979 980 980 979 972 971 974 974 974 971 972 972

0303 Pearson r 1.000 .556 .369 0 .396 .404 .430 .430 .228 .169 .284 .382 .339 .352

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 988 987 979 980 980 979 972 971 975 975 975 972 973 973

0304 Pearson r .556 1.000 .317 0 .374 .412 .441 .450 .212 .161 .278 .460 .387 .453

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 987 987 978 979 979 978 971 970 975 975 975 972 973 973

0401 Pearson r .369 .317 1.000 1 .576 .629 .562 .445 .336 .298 .329 .347 .387 .301

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 979 978 979 979 979 978 971 970 972 972 972 969 970 970

0402 Pearson r .317 .269 .567 1 .496 .526 .449 .306 .192 .209 .263 .260 .290 .238

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 980 979 979 980 980 979 972 971 973 973 973 970 971 971

0403 Pearson r .396 .374 .576 0 1.000 .630 .590 .531 .299 .280 .332 .341 .389 .372

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 980 979 979 980 980 979 972 971 973 973 973 970 971 971

0404 Pearson r .404 .412 .629 1 .630 1.000 .643 .541 .300 .258 .372 .387 .421 .370

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 979 978 978 979 979 979 972 971 973 973 973 970 971 971



0405 Pearson r .430 .441 .562 0 .590 .643 1.000 .609 .336 .294 .410 .417 .438 .405

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 972 971 971 972 972 972 972 971 966 966 966 964 965 965

0406 Pearson r .430 .450 .445 0 .531 .541 .609 1.000 .369 .303 .410 .416 .472 .461

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 971 970 970 971 971 971 971 971 965 965 965 964 964 964

0501 Pearson r .228 .212 .336 0 .299 .300 .336 .369 1.000 .651 .562 .388 .446 .389

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 975 975 972 973 973 973 966 965 975 975 975 972 973 973

0502 Pearson r .169 .161 .298 0 .280 .258 .294 .303 .651 1.000 .534 .329 .389 .344

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 975 975 972 973 973 973 966 965 975 975 975 972 973 973

0503 Pearson r .284 .278 .329 0 .332 .372 .410 .410 .562 .534 1.000 .521 .559 .444

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 975 975 972 973 973 973 966 965 975 975 975 972 973 973

0504 Pearson r .382 .460 .347 0 .341 .387 .417 .416 .388 .329 .521 1.000 .573 .520

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 972 972 969 970 970 970 964 964 972 972 972 972 972 972

0505 Pearson r .339 .387 .387 0 .389 .421 .438 .472 .446 .389 .559 .573 1.000 .524

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 973 973 970 971 971 971 965 964 973 973 973 972 973 973

0506 Pearson r .352 .453 .301 0 .372 .370 .405 .461 .389 .344 .444 .520 .524 1.000

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 973 973 970 971 971 971 965 964 973 973 973 972 973 973

Frequency Criticality 0101 0102 0103 0104 0105 0106 0107 0201 0202 0203 0204 0205 0301 0302

0101 Pearson r .398 0 .236 .208 .119 .211 .212 .155 .151 .140 .088 .147 .111 .002

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .005 .000 .000 .940

N 1037 1037 1034 1026 1024 1022 1019 993 993 993 990 990 985 984

0102 Pearson r .182 0 .208 .223 .145 .201 .202 .209 .184 .166 .098 .171 .101 .019

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .002 .000 .001 .549

N 1037 1037 1034 1026 1024 1022 1019 993 993 993 990 990 985 984

0103 Pearson r .222 0 .349 .232 .139 .205 .218 .164 .175 .178 .099 .161 .108 ‐.017

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .002 .000 .001 .584

N 1034 1034 1036 1028 1026 1024 1021 994 994 994 991 991 986 985

0104 Pearson r .192 0 .179 .366 .191 .198 .135 .171 .139 .167 .088 .170 .135 .059

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .006 .000 .000 .064

N 1025 1025 1027 1027 1025 1023 1020 988 988 988 987 987 981 980

0105 Pearson r .143 0 .192 .249 .306 .189 .169 .184 .175 .157 .105 .176 .175 .040

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .001 .000 .000 .210

N 1023 1023 1025 1025 1025 1022 1019 988 988 988 987 987 981 980

0106 Pearson r .081 0 .135 .201 .064 .392 .192 .116 .085 .069 .069 .054 .112 ‐.022

p value .010 .033 .000 .000 .040 .000 .000 .000 .008 .030 .030 .089 .000 .491

N 1021 1021 1023 1023 1022 1023 1020 987 987 987 986 986 980 979

0107 Pearson r .119 0 .177 .169 .018 .241 .291 .078 .034 .045 .032 .073 .061 ‐.113

p value .000 .031 .000 .000 .575 .000 .000 .014 .289 .160 .312 .023 .058 .000

N 1017 1017 1019 1019 1018 1019 1019 987 987 987 986 986 980 979



0201 Pearson r .056 0 .104 .147 .128 .078 .065 .198 .124 .169 .147 .151 .207 .117

p value .076 .000 .001 .000 .000 .014 .041 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0202 Pearson r .076 0 .083 .167 .132 .063 .057 .189 .248 .250 .195 .200 .213 .217

p value .016 .000 .009 .000 .000 .049 .073 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0203 Pearson r .093 0 .106 .188 .105 .070 .077 .146 .205 .276 .209 .196 .191 .179

p value .003 .000 .001 .000 .001 .029 .015 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0204 Pearson r .090 0 .091 .136 .116 .090 .024 .141 .205 .245 .267 .192 .201 .192

p value .005 .000 .004 .000 .000 .005 .457 .000 .000 .000 .000 .000 .000 .000

N 990 990 991 987 987 986 986 994 994 994 994 994 987 986

0205 Pearson r .101 0 .112 .127 .110 .091 .087 .142 .158 .209 .200 .286 .216 .153

p value .001 .000 .000 .000 .001 .004 .006 .000 .000 .000 .000 .000 .000 .000

N 990 990 991 987 987 986 986 994 994 994 994 994 987 986

0301 Pearson r .132 0 .126 .174 .108 .102 .150 .181 .222 .214 .166 .213 .113 .081

p value .000 .000 .000 .000 .001 .001 .000 .000 .000 .000 .000 .000 .000 .011

N 985 985 986 981 981 980 980 988 988 988 987 987 988 987

0302 Pearson r .165 0 .130 .221 .149 .155 .167 .189 .207 .192 .133 .206 .151 ‐.002

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .962

N 984 984 985 980 980 979 979 987 987 987 986 986 987 987

0303 Pearson r .098 0 .085 .174 .137 .145 .135 .167 .190 .158 .111 .180 .113 .028

p value .002 .004 .008 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .375

N 984 984 985 980 980 979 979 987 987 987 986 986 987 987

0304 Pearson r .147 0 .158 .242 .138 .204 .182 .159 .183 .157 .097 .161 .147 .002

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .002 .000 .000 .938

N 983 983 984 980 980 979 979 986 986 986 986 986 986 986

0401 Pearson r .070 0 .137 .147 .097 .157 .126 .113 .089 .118 .114 .103 .168 .052

p value .028 .000 .000 .000 .003 .000 .000 .000 .005 .000 .000 .001 .000 .105

N 978 978 978 975 975 975 975 979 979 979 978 978 979 979

0402 Pearson r .105 0 .116 .169 .135 .183 .112 .109 .112 .176 .121 .117 .116 .129

p value .001 .000 .000 .000 .000 .000 .000 .001 .000 .000 .000 .000 .000 .000

N 978 978 979 976 976 976 976 980 980 980 979 979 980 980

0403 Pearson r .134 0 .149 .149 .092 .182 .137 .127 .149 .168 .137 .162 .160 .040

p value .000 .000 .000 .000 .004 .000 .000 .000 .000 .000 .000 .000 .000 .212

N 978 978 979 976 976 976 976 980 980 980 979 979 980 980

0404 Pearson r .128 0 .117 .133 .127 .127 .127 .143 .150 .183 .157 .131 .166 .108

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .001

N 977 977 978 975 975 975 975 979 979 979 978 978 979 979

0405 Pearson r .103 0 .144 .149 .115 .154 .110 .148 .164 .193 .181 .169 .179 .130

p value .001 .000 .000 .000 .000 .000 .001 .000 .000 .000 .000 .000 .000 .000

N 970 970 971 969 969 969 969 972 972 972 971 971 972 972

0406 Pearson r .123 0 .160 .158 .108 .187 .183 .153 .180 .140 .113 .166 .153 .041

p value .000 .000 .000 .000 .001 .000 .000 .000 .000 .000 .000 .000 .000 .201

N 969 969 970 968 968 968 968 971 971 971 970 970 971 971

0501 Pearson r .101 0 .147 .176 .098 .141 .123 .127 .111 .085 .078 .092 .102 ‐.002

p value .002 .000 .000 .000 .002 .000 .000 .000 .000 .008 .015 .004 .001 .962

N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0502 Pearson r .068 0 .095 .094 .101 .076 .144 .052 .060 .009 .004 .033 .042 ‐.068

p value .034 .015 .003 .003 .002 .019 .000 .102 .063 .769 .892 .297 .186 .034



N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0503 Pearson r .064 0 .109 .128 .135 .090 .070 .124 .112 .130 .132 .098 .088 .140

p value .047 .000 .001 .000 .000 .005 .029 .000 .000 .000 .000 .002 .006 .000

N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0504 Pearson r .127 0 .157 .175 .145 .162 .117 .127 .130 .112 .083 .106 .132 .041

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .010 .001 .000 .201

N 969 969 970 968 968 968 968 972 972 972 972 972 971 971

0505 Pearson r .140 0 .144 .195 .146 .117 .137 .142 .110 .130 .109 .147 .128 .029

p value .000 .000 .000 .000 .000 .000 .000 .000 .001 .000 .001 .000 .000 .369

N 970 970 971 969 969 969 969 973 973 973 973 973 972 972

0506 Pearson r .124 0 .158 .109 .081 .163 .177 .050 .070 .046 .023 .072 .067 ‐.091

p value .000 .002 .000 .001 .012 .000 .000 .119 .030 .156 .468 .025 .035 .005

N 970 970 971 969 969 969 969 973 973 973 973 973 972 972


0101 Pearson r .084 .097 .130 0 .122 .154 .156 .162 .182 .124 .184 .135 .198 .121

p value .008 .002 .000 .002 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 984 983 978 978 978 977 970 969 972 972 972 969 970 970

0102 Pearson r .063 .129 .174 0 .134 .160 .175 .159 .174 .139 .218 .175 .255 .182

p value .048 .000 .000 .001 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 984 983 978 978 978 977 970 969 972 972 972 969 970 970

0103 Pearson r .062 .080 .172 0 .119 .152 .133 .149 .182 .153 .158 .098 .186 .113

p value .050 .012 .000 .000 .000 .000 .000 .000 .000 .000 .000 .002 .000 .000

N 985 984 978 979 979 978 971 970 973 973 973 970 971 971

0104 Pearson r .130 .138 .180 0 .197 .214 .214 .187 .184 .130 .163 .184 .265 .184

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 980 980 975 976 976 975 969 968 970 970 970 968 969 969

0105 Pearson r .114 .140 .146 0 .162 .163 .191 .181 .140 .130 .146 .149 .190 .146

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 980 980 975 976 976 975 969 968 970 970 970 968 969 969

0106 Pearson r .065 .066 .148 0 .125 .125 .136 .101 .144 .093 .096 .107 .111 .104

p value .042 .038 .000 .000 .000 .000 .000 .002 .000 .004 .003 .001 .001 .001

N 979 979 975 976 976 975 969 968 970 970 970 968 969 969

0107 Pearson r ‐.006

.018 .099 0 .090 .066 .088 .118 .151 .167 .107 .078 .139 .126

p value .845 .567 .002 .026 .005 .040 .006 .000 .000 .000 .001 .015 .000 .000

N 979 979 975 976 976 975 969 968 970 970 970 968 969 969

0201 Pearson r .154 .154 .196 0 .132 .151 .169 .141 .107 .050 .122 .152 .194 .120

p value .000 .000 .000 .000 .000 .000 .000 .000 .001 .122 .000 .000 .000 .000

N 988 987 979 980 980 979 972 971 975 975 975 972 973 973

0202 Pearson r .222 .216 .177 0 .162 .211 .205 .158 .061 .012 .115 .165 .194 .122

p value .000 .000 .000 .000 .000 .000 .000 .000 .057 .710 .000 .000 .000 .000

N 988 987 979 980 980 979 972 971 975 975 975 972 973 973

0203 Pearson r .190 .215 .187 0 .176 .211 .204 .189 .061 .010 .130 .139 .189 .137

p value .000 .000 .000 .000 .000 .000 .000 .000 .056 .758 .000 .000 .000 .000

N 988 987 979 980 980 979 972 971 975 975 975 972 973 973

0204 Pearson r .194 .201 .179 0 .150 .213 .200 .174 .083 .016 .116 .144 .172 .157



p value .000 .000 .000 .000 .000 .000 .000 .000 .009 .619 .000 .000 .000 .000

N 987 987 978 979 979 978 971 970 975 975 975 972 973 973

0205 Pearson r .246 .177 .193 0 .164 .197 .223 .186 .120 .045 .120 .180 .200 .158

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .164 .000 .000 .000 .000

N 987 987 978 979 979 978 971 970 975 975 975 972 973 973

0301 Pearson r .111 .142 .155 0 .182 .192 .179 .176 .102 .046 .107 .114 .199 .135

p value .000 .000 .000 .000 .000 .000 .000 .000 .001 .152 .001 .000 .000 .000

N 987 986 979 980 980 979 972 971 974 974 974 971 972 972

0302 Pearson r .053 .107 .153 0 .159 .170 .177 .169 .222 .177 .218 .088 .231 .111

p value .097 .001 .000 .001 .000 .000 .000 .000 .000 .000 .000 .006 .000 .001

N 987 986 979 980 980 979 972 971 974 974 974 971 972 972


.083 .127 0 .134 .145 .173 .157 .128 .130 .146 .048 .194 .108

p value .941 .009 .000 .000 .000 .000 .000 .000 .000 .000 .000 .138 .000 .001

N 987 986 979 980 980 979 972 971 974 974 974 971 972 972

0304 Pearson r .058 .124 .175 0 .169 .167 .185 .176 .161 .167 .189 .102 .228 .112

p value .069 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .002 .000 .000

N 986 986 978 979 979 978 971 970 974 974 974 971 972 972

0401 Pearson r .180 .139 .261 0 .168 .210 .217 .170 .172 .050 .140 .130 .147 .135

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .121 .000 .000 .000 .000

N 979 978 979 979 979 978 971 970 972 972 972 969 970 970

0402 Pearson r .182 .155 .253 0 .189 .247 .223 .152 .104 .044 .101 .136 .124 .139

p value .000 .000 .000 .000 .000 .000 .000 .000 .001 .167 .002 .000 .000 .000

N 980 979 979 980 980 979 972 971 973 973 973 970 971 971

0403 Pearson r .153 .121 .210 0 .257 .196 .218 .234 .132 .088 .102 .125 .140 .137

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .006 .002 .000 .000 .000

N 980 979 979 980 980 979 972 971 973 973 973 970 971 971

0404 Pearson r .162 .155 .197 0 .209 .301 .259 .239 .091 .037 .127 .164 .166 .166

p value .000 .000 .000 .000 .000 .000 .000 .000 .005 .252 .000 .000 .000 .000

N 979 978 978 979 979 979 972 971 973 973 973 970 971 971

0405 Pearson r .204 .189 .197 0 .202 .260 .328 .235 .112 .038 .155 .173 .195 .174

p value .000 .000 .000 .000 .000 .000 .000 .000 .001 .244 .000 .000 .000 .000

N 972 971 971 972 972 972 972 971 966 966 966 964 965 965

0406 Pearson r .141 .153 .160 0 .156 .176 .247 .297 .135 .097 .167 .150 .203 .163

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .003 .000 .000 .000 .000

N 971 970 970 971 971 971 971 971 965 965 965 964 964 964

0501 Pearson r .092 .046 .115 0 .077 .106 .124 .139 .315 .172 .175 .147 .173 .142

p value .004 .152 .000 .001 .016 .001 .000 .000 .000 .000 .000 .000 .000 .000

N 975 975 972 973 973 973 966 965 975 975 975 972 973 973


‐.006

.058 0 .056 .065 .087 .082 .164 .256 .150 .053 .082 .067

p value .426 .858 .069 .024 .079 .042 .007 .011 .000 .000 .000 .100 .011 .038

N 975 975 972 973 973 973 966 965 975 975 975 972 973 973

0503 Pearson r .131 .118 .090 0 .117 .158 .161 .142 .114 .084 .287 .179 .167 .177

p value .000 .000 .005 .002 .000 .000 .000 .000 .000 .009 .000 .000 .000 .000

N 975 975 972 973 973 973 966 965 975 975 975 972 973 973

0504 Pearson r .080 .122 .119 0 .088 .135 .173 .172 .187 .138 .246 .256 .249 .176



p value .012 .000 .000 .001 .006 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 972 972 969 970 970 970 964 964 972 972 972 972 972 972

0505 Pearson r .069 .112 .151 0 .112 .183 .157 .135 .210 .170 .226 .210 .402 .230

p value .030 .000 .000 .016 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 973 973 970 971 971 971 965 964 973 973 973 972 973 973

0506 Pearson r .029 .040 .077 0 .066 .071 .117 .126 .175 .200 .186 .094 .175 .195

p value .371 .209 .016 .207 .039 .026 .000 .000 .000 .000 .000 .003 .000 .000

N 973 973 970 971 971 971 965 964 973 973 973 972 973 973

Criticality Frequency 0101 0102 0103 0104 0105 0106 0107 0201 0202 0203 0204 0205 0301 0302

0101 Pearson r .398 0 .222 .192 .143 .081 .119 .056 .076 .093 .090 .101 .132 .165

p value .000 .000 .000 .000 .000 .010 .000 .076 .016 .003 .005 .001 .000 .000

N 1037 1037 1034 1025 1023 1021 1017 993 993 993 990 990 985 984

0102 Pearson r .177 0 .154 .181 .168 .067 .068 .147 .155 .161 .164 .157 .167 .136

p value .000 .000 .000 .000 .000 .033 .031 .000 .000 .000 .000 .000 .000 .000

N 1037 1037 1034 1025 1023 1021 1017 993 993 993 990 990 985 984

0103 Pearson r .236 0 .349 .179 .192 .135 .177 .104 .083 .106 .091 .112 .126 .130

p value .000 .000 .000 .000 .000 .000 .000 .001 .009 .001 .004 .000 .000 .000

N 1034 1034 1036 1027 1025 1023 1019 994 994 994 991 991 986 985

0104 Pearson r .208 0 .232 .366 .249 .201 .169 .147 .167 .188 .136 .127 .174 .221

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1026 1026 1028 1027 1025 1023 1019 988 988 988 987 987 981 980

0105 Pearson r .119 0 .139 .191 .306 .064 .018 .128 .132 .105 .116 .110 .108 .149

p value .000 .000 .000 .000 .000 .040 .575 .000 .000 .001 .000 .001 .001 .000

N 1024 1024 1026 1025 1025 1022 1018 988 988 988 987 987 981 980

0106 Pearson r .211 0 .205 .198 .189 .392 .241 .078 .063 .070 .090 .091 .102 .155

p value .000 .000 .000 .000 .000 .000 .000 .014 .049 .029 .005 .004 .001 .000

N 1022 1022 1024 1023 1022 1023 1019 987 987 987 986 986 980 979

0107 Pearson r .212 0 .218 .135 .169 .192 .291 .065 .057 .077 .024 .087 .150 .167

p value .000 .000 .000 .000 .000 .000 .000 .041 .073 .015 .457 .006 .000 .000

N 1019 1019 1021 1020 1019 1020 1019 987 987 987 986 986 980 979

0201 Pearson r .155 0 .164 .171 .184 .116 .078 .198 .189 .146 .141 .142 .181 .189

p value .000 .000 .000 .000 .000 .000 .014 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0202 Pearson r .151 0 .175 .139 .175 .085 .034 .124 .248 .205 .205 .158 .222 .207

p value .000 .000 .000 .000 .000 .008 .289 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0203 Pearson r .140 0 .178 .167 .157 .069 .045 .169 .250 .276 .245 .209 .214 .192

p value .000 .000 .000 .000 .000 .030 .160 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0204 Pearson r .088 0 .099 .088 .105 .069 .032 .147 .195 .209 .267 .200 .166 .133

p value .005 .002 .002 .006 .001 .030 .312 .000 .000 .000 .000 .000 .000 .000

N 990 990 991 987 987 986 986 994 994 994 994 994 987 986

0205 Pearson r .147 0 .161 .170 .176 .054 .073 .151 .200 .196 .192 .286 .213 .206

p value .000 .000 .000 .000 .000 .089 .023 .000 .000 .000 .000 .000 .000 .000

N 990 990 991 987 987 986 986 994 994 994 994 994 987 986



0301 Pearson r .111 0 .108 .135 .175 .112 .061 .207 .213 .191 .201 .216 .113 .151

p value .000 .001 .001 .000 .000 .000 .058 .000 .000 .000 .000 .000 .000 .000

N 985 985 986 981 981 980 980 988 988 988 987 987 988 987

0302 Pearson r .002 0 ‐.017

.059 .040 ‐.022

‐.113

.117 .217 .179 .192 .153 .081 ‐.002

p value .940 .549 .584 .064 .210 .491 .000 .000 .000 .000 .000 .000 .011 .962

N 984 984 985 980 980 979 979 987 987 987 986 986 987 987

0303 Pearson r .084 0 .062 .130 .114 .065 ‐.006

.154 .222 .190 .194 .246 .111 .053

p value .008 .048 .050 .000 .000 .042 .845 .000 .000 .000 .000 .000 .000 .097

N 984 984 985 980 980 979 979 988 988 988 987 987 987 987

0304 Pearson r .097 0 .080 .138 .140 .066 .018 .154 .216 .215 .201 .177 .142 .107

p value .002 .000 .012 .000 .000 .038 .567 .000 .000 .000 .000 .000 .000 .001

N 983 983 984 980 980 979 979 987 987 987 987 987 986 986

0401 Pearson r .130 0 .172 .180 .146 .148 .099 .196 .177 .187 .179 .193 .155 .153

p value .000 .000 .000 .000 .000 .000 .002 .000 .000 .000 .000 .000 .000 .000

N 978 978 978 975 975 975 975 979 979 979 978 978 979 979

0402 Pearson r .099 0 .135 .151 .145 .142 .071 .168 .174 .202 .162 .159 .124 .107

p value .002 .001 .000 .000 .000 .000 .026 .000 .000 .000 .000 .000 .000 .001

N 978 978 979 976 976 976 976 980 980 980 979 979 980 980

0403 Pearson r .122 0 .119 .197 .162 .125 .090 .132 .162 .176 .150 .164 .182 .159

p value .000 .000 .000 .000 .000 .000 .005 .000 .000 .000 .000 .000 .000 .000

N 978 978 979 976 976 976 976 980 980 980 979 979 980 980

0404 Pearson r .154 0 .152 .214 .163 .125 .066 .151 .211 .211 .213 .197 .192 .170

p value .000 .000 .000 .000 .000 .000 .040 .000 .000 .000 .000 .000 .000 .000

N 977 977 978 975 975 975 975 979 979 979 978 978 979 979

0405 Pearson r .156 0 .133 .214 .191 .136 .088 .169 .205 .204 .200 .223 .179 .177

p value .000 .000 .000 .000 .000 .000 .006 .000 .000 .000 .000 .000 .000 .000

N 970 970 971 969 969 969 969 972 972 972 971 971 972 972

0406 Pearson r .162 0 .149 .187 .181 .101 .118 .141 .158 .189 .174 .186 .176 .169

p value .000 .000 .000 .000 .000 .002 .000 .000 .000 .000 .000 .000 .000 .000

N 969 969 970 968 968 968 968 971 971 971 970 970 971 971

0501 Pearson r .182 0 .182 .184 .140 .144 .151 .107 .061 .061 .083 .120 .102 .222

p value .000 .000 .000 .000 .000 .000 .000 .001 .057 .056 .009 .000 .001 .000

N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0502 Pearson r .124 0 .153 .130 .130 .093 .167 .050 .012 .010 .016 .045 .046 .177

p value .000 .000 .000 .000 .000 .004 .000 .122 .710 .758 .619 .164 .152 .000

N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0503 Pearson r .184 0 .158 .163 .146 .096 .107 .122 .115 .130 .116 .120 .107 .218

p value .000 .000 .000 .000 .000 .003 .001 .000 .000 .000 .000 .000 .001 .000

N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0504 Pearson r .135 0 .098 .184 .149 .107 .078 .152 .165 .139 .144 .180 .114 .088

p value .000 .000 .002 .000 .000 .001 .015 .000 .000 .000 .000 .000 .000 .006

N 969 969 970 968 968 968 968 972 972 972 972 972 971 971

0505 Pearson r .198 0 .186 .265 .190 .111 .139 .194 .194 .189 .172 .200 .199 .231

p value .000 .000 .000 .000 .000 .001 .000 .000 .000 .000 .000 .000 .000 .000

N 970 970 971 969 969 969 969 973 973 973 973 973 972 972



0506 Pearson r .121 0 .113 .184 .146 .104 .126 .120 .122 .137 .157 .158 .135 .111

p value .000 .000 .000 .000 .000 .001 .000 .000 .000 .000 .000 .000 .000 .001

N 970 970 971 969 969 969 969 973 973 973 973 973 972 972


0101 Pearson r .098 .147 .070 0 .134 .128 .103 .123 .101 .068 .064 .127 .140 .124

p value .002 .000 .028 .001 .000 .000 .001 .000 .002 .034 .047 .000 .000 .000

N 984 983 978 978 978 977 970 969 972 972 972 969 970 970

0102 Pearson r .093 .128 .120 0 .142 .166 .175 .127 .157 .078 .149 .174 .164 .100

p value .004 .000 .000 .000 .000 .000 .000 .000 .000 .015 .000 .000 .000 .002

N 984 983 978 978 978 977 970 969 972 972 972 969 970 970

0103 Pearson r .085 .158 .137 0 .149 .117 .144 .160 .147 .095 .109 .157 .144 .158

p value .008 .000 .000 .000 .000 .000 .000 .000 .000 .003 .001 .000 .000 .000

N 985 984 978 979 979 978 971 970 973 973 973 970 971 971

0104 Pearson r .174 .242 .147 0 .149 .133 .149 .158 .176 .094 .128 .175 .195 .109

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .003 .000 .000 .000 .001

N 980 980 975 976 976 975 969 968 970 970 970 968 969 969

0105 Pearson r .137 .138 .097 0 .092 .127 .115 .108 .098 .101 .135 .145 .146 .081

p value .000 .000 .003 .000 .004 .000 .000 .001 .002 .002 .000 .000 .000 .012

N 980 980 975 976 976 975 969 968 970 970 970 968 969 969

0106 Pearson r .145 .204 .157 0 .182 .127 .154 .187 .141 .076 .090 .162 .117 .163

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .019 .005 .000 .000 .000

N 979 979 975 976 976 975 969 968 970 970 970 968 969 969

0107 Pearson r .135 .182 .126 0 .137 .127 .110 .183 .123 .144 .070 .117 .137 .177

p value .000 .000 .000 .000 .000 .000 .001 .000 .000 .000 .029 .000 .000 .000

N 979 979 975 976 976 975 969 968 970 970 970 968 969 969

0201 Pearson r .167 .159 .113 0 .127 .143 .148 .153 .127 .052 .124 .127 .142 .050

p value .000 .000 .000 .001 .000 .000 .000 .000 .000 .102 .000 .000 .000 .119

N 987 986 979 980 980 979 972 971 975 975 975 972 973 973

0202 Pearson r .190 .183 .089 0 .149 .150 .164 .180 .111 .060 .112 .130 .110 .070

p value .000 .000 .005 .000 .000 .000 .000 .000 .000 .063 .000 .000 .001 .030

N 987 986 979 980 980 979 972 971 975 975 975 972 973 973

0203 Pearson r .158 .157 .118 0 .168 .183 .193 .140 .085 .009 .130 .112 .130 .046

p value .000 .000 .000 .000 .000 .000 .000 .000 .008 .769 .000 .000 .000 .156

N 987 986 979 980 980 979 972 971 975 975 975 972 973 973

0204 Pearson r .111 .097 .114 0 .137 .157 .181 .113 .078 .004 .132 .083 .109 .023

p value .000 .002 .000 .000 .000 .000 .000 .000 .015 .892 .000 .010 .001 .468

N 986 986 978 979 979 978 971 970 975 975 975 972 973 973

0205 Pearson r .180 .161 .103 0 .162 .131 .169 .166 .092 .033 .098 .106 .147 .072

p value .000 .000 .001 .000 .000 .000 .000 .000 .004 .297 .002 .001 .000 .025

N 986 986 978 979 979 978 971 970 975 975 975 972 973 973

0301 Pearson r .113 .147 .168 0 .160 .166 .179 .153 .102 .042 .088 .132 .128 .067

p value .000 .000 .000 .000 .000 .000 .000 .000 .001 .186 .006 .000 .000 .035

N 987 986 979 980 980 979 972 971 974 974 974 971 972 972

0302 Pearson r .028 .002 .052 0 .040 .108 .130 .041 ‐.002

‐.068

.140 .041 .029 ‐.091

p value .375 .938 .105 .000 .212 .001 .000 .201 .962 .034 .000 .201 .369 .005



N 987 986 979 980 980 979 972 971 974 974 974 971 972 972


.058 .180 0 .153 .162 .204 .141 .092 ‐.026

.131 .080 .069 .029

p value .941 .069 .000 .000 .000 .000 .000 .000 .004 .426 .000 .012 .030 .371

N 987 986 979 980 980 979 972 971 975 975 975 972 973 973

0304 Pearson r .083 .124 .139 0 .121 .155 .189 .153 .046 ‐.006

.118 .122 .112 .040

p value .009 .000 .000 .000 .000 .000 .000 .000 .152 .858 .000 .000 .000 .209

N 986 986 978 979 979 978 971 970 975 975 975 972 973 973

0401 Pearson r .127 .175 .261 0 .210 .197 .197 .160 .115 .058 .090 .119 .151 .077

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .069 .005 .000 .000 .016

N 979 978 979 979 979 978 971 970 972 972 972 969 970 970

0402 Pearson r .113 .151 .177 0 .158 .186 .178 .117 .108 .072 .101 .104 .077 .041

p value .000 .000 .000 .000 .000 .000 .000 .000 .001 .024 .002 .001 .016 .207

N 980 979 979 980 980 979 972 971 973 973 973 970 971 971

0403 Pearson r .134 .169 .168 0 .257 .209 .202 .156 .077 .056 .117 .088 .112 .066

p value .000 .000 .000 .000 .000 .000 .000 .000 .016 .079 .000 .006 .000 .039

N 980 979 979 980 980 979 972 971 973 973 973 970 971 971

0404 Pearson r .145 .167 .210 0 .196 .301 .260 .176 .106 .065 .158 .135 .183 .071

p value .000 .000 .000 .000 .000 .000 .000 .000 .001 .042 .000 .000 .000 .026

N 979 978 978 979 979 979 972 971 973 973 973 970 971 971

0405 Pearson r .173 .185 .217 0 .218 .259 .328 .247 .124 .087 .161 .173 .157 .117

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .007 .000 .000 .000 .000

N 972 971 971 972 972 972 972 971 966 966 966 964 965 965

0406 Pearson r .157 .176 .170 0 .234 .239 .235 .297 .139 .082 .142 .172 .135 .126

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .011 .000 .000 .000 .000

N 971 970 970 971 971 971 971 971 965 965 965 964 964 964

0501 Pearson r .128 .161 .172 0 .132 .091 .112 .135 .315 .164 .114 .187 .210 .175

p value .000 .000 .000 .001 .000 .005 .001 .000 .000 .000 .000 .000 .000 .000

N 974 974 972 973 973 973 966 965 975 975 975 972 973 973

0502 Pearson r .130 .167 .050 0 .088 .037 .038 .097 .172 .256 .084 .138 .170 .200

p value .000 .000 .121 .167 .006 .252 .244 .003 .000 .000 .009 .000 .000 .000

N 974 974 972 973 973 973 966 965 975 975 975 972 973 973

0503 Pearson r .146 .189 .140 0 .102 .127 .155 .167 .175 .150 .287 .246 .226 .186

p value .000 .000 .000 .002 .002 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 974 974 972 973 973 973 966 965 975 975 975 972 973 973

0504 Pearson r .048 .102 .130 0 .125 .164 .173 .150 .147 .053 .179 .256 .210 .094

p value .138 .002 .000 .000 .000 .000 .000 .000 .000 .100 .000 .000 .000 .003

N 971 971 969 970 970 970 964 964 972 972 972 972 972 972

0505 Pearson r .194 .228 .147 0 .140 .166 .195 .203 .173 .082 .167 .249 .402 .175

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .011 .000 .000 .000 .000

N 972 972 970 971 971 971 965 964 973 973 973 972 973 973

0506 Pearson r .108 .112 .135 0 .137 .166 .174 .163 .142 .067 .177 .176 .230 .195

p value .001 .000 .000 .000 .000 .000 .000 .000 .000 .038 .000 .000 .000 .000

N 972 972 970 971 971 971 965 964 973 973 973 972 973 973

Frequency Frequency 0101 0102 0103 0104 0105 0106 0107 0201 0202 0203 0204 0205 0301 0302



0101 Pearson r 1.000 0 .444 .363 .304 .275 .395 .193 .199 .190 .167 .197 .261 .211

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1037 1037 1034 1025 1023 1021 1017 993 993 993 990 990 985 984

0102 Pearson r .410 1 .467 .343 .332 .297 .303 .256 .238 .271 .249 .214 .362 .323

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1037 1037 1034 1025 1023 1021 1017 993 993 993 990 990 985 984

0103 Pearson r .444 0 1.000 .371 .335 .370 .415 .239 .203 .206 .166 .208 .296 .218

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1034 1034 1036 1027 1025 1023 1019 994 994 994 991 991 986 985

0104 Pearson r .363 0 .371 1.000 .420 .274 .336 .257 .259 .275 .225 .240 .306 .202

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1025 1025 1027 1027 1025 1023 1019 988 988 988 987 987 981 980

0105 Pearson r .304 0 .335 .420 1.000 .273 .314 .252 .292 .264 .251 .235 .308 .345

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1023 1023 1025 1025 1025 1022 1018 988 988 988 987 987 981 980

0106 Pearson r .275 0 .370 .274 .273 1.000 .496 .141 .118 .122 .112 .134 .189 .147

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 1021 1021 1023 1023 1022 1023 1019 987 987 987 986 986 980 979

0107 Pearson r .395 0 .415 .336 .314 .496 1.000 .161 .134 .153 .106 .177 .234 .236

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .001 .000 .000 .000

N 1017 1017 1019 1019 1018 1019 1019 987 987 987 986 986 980 979

0201 Pearson r .193 0 .239 .257 .252 .141 .161 1.000 .595 .550 .511 .516 .345 .183

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0202 Pearson r .199 0 .203 .259 .292 .118 .134 .595 1.000 .810 .702 .594 .470 .301

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0203 Pearson r .190 0 .206 .275 .264 .122 .153 .550 .810 1.000 .707 .600 .477 .286

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 993 993 994 988 988 987 987 997 997 997 994 994 988 987

0204 Pearson r .167 0 .166 .225 .251 .112 .106 .511 .702 .707 1.000 .603 .412 .299

p value .000 .000 .000 .000 .000 .000 .001 .000 .000 .000 .000 .000 .000

N 990 990 991 987 987 986 986 994 994 994 994 994 987 986

0205 Pearson r .197 0 .208 .240 .235 .134 .177 .516 .594 .600 .603 1.000 .447 .254

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 990 990 991 987 987 986 986 994 994 994 994 994 987 986

0301 Pearson r .261 0 .296 .306 .308 .189 .234 .345 .470 .477 .412 .447 1.000 .418

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 985 985 986 981 981 980 980 988 988 988 987 987 988 987

0302 Pearson r .211 0 .218 .202 .345 .147 .236 .183 .301 .286 .299 .254 .418 1.000

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 984 984 985 980 980 979 979 987 987 987 986 986 987 987

0303 Pearson r .206 0 .243 .216 .314 .171 .226 .180 .282 .291 .278 .255 .432 .632

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 984 984 985 980 980 979 979 987 987 987 986 986 987 987

0304 Pearson r .227 0 .330 .273 .357 .211 .276 .204 .249 .254 .220 .196 .397 .657

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 983 983 984 980 980 979 979 986 986 986 986 986 986 986

0401 Pearson r .214 0 .252 .280 .223 .303 .219 .296 .336 .354 .329 .364 .337 .175

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 978 978 978 975 975 975 975 979 979 979 978 978 979 979

0402 Pearson r .178 0 .207 .252 .199 .257 .146 .210 .286 .300 .247 .259 .285 .110



p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .001

N 978 978 979 976 976 976 976 980 980 980 979 979 980 980

0403 Pearson r .233 0 .282 .244 .276 .246 .227 .209 .277 .304 .270 .277 .309 .298

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 978 978 979 976 976 976 976 980 980 980 979 979 980 980

0404 Pearson r .247 0 .231 .288 .297 .243 .214 .309 .400 .394 .381 .416 .364 .250

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 977 977 978 975 975 975 975 979 979 979 978 978 979 979

0405 Pearson r .285 0 .208 .309 .263 .230 .228 .328 .399 .413 .397 .420 .366 .248

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 970 970 971 969 969 969 969 972 972 972 971 971 972 972

0406 Pearson r .280 0 .305 .271 .265 .252 .303 .282 .355 .373 .320 .363 .382 .292

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 969 969 970 968 968 968 968 971 971 971 970 970 971 971

0501 Pearson r .219 0 .241 .225 .246 .271 .257 .129 .153 .164 .135 .149 .218 .248

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0502 Pearson r .189 0 .243 .172 .238 .189 .287 .055 .070 .085 .014 .083 .185 .208

p value .000 .000 .000 .000 .000 .000 .000 .086 .029 .008 .659 .009 .000 .000

N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0503 Pearson r .127 0 .143 .261 .187 .094 .142 .164 .208 .214 .220 .203 .198 .154

p value .000 .003 .000 .000 .000 .003 .000 .000 .000 .000 .000 .000 .000 .000

N 972 972 973 970 970 970 970 975 975 975 975 975 974 974

0504 Pearson r .307 0 .308 .290 .340 .250 .277 .228 .259 .267 .247 .254 .300 .377

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 969 969 970 968 968 968 968 972 972 972 972 972 971 971

0505 Pearson r .270 0 .256 .323 .314 .181 .321 .195 .217 .253 .220 .238 .264 .294

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 970 970 971 969 969 969 969 973 973 973 973 973 972 972

0506 Pearson r .326 0 .334 .275 .292 .302 .383 .159 .161 .163 .156 .195 .258 .270

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 970 970 971 969 969 969 969 973 973 973 973 973 972 972


0101 Pearson r .206 .227 .214 0 .233 .247 .285 .280 .219 .189 .127 .307 .270 .326

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 984 983 978 978 978 977 970 969 972 972 972 969 970 970

0102 Pearson r .335 .373 .226 0 .270 .279 .268 .322 .247 .204 .094 .374 .292 .332

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .003 .000 .000 .000

N 984 983 978 978 978 977 970 969 972 972 972 969 970 970

0103 Pearson r .243 .330 .252 0 .282 .231 .208 .305 .241 .243 .143 .308 .256 .334

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 985 984 978 979 979 978 971 970 973 973 973 970 971 971

0104 Pearson r .216 .273 .280 0 .244 .288 .309 .271 .225 .172 .261 .290 .323 .275

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 980 980 975 976 976 975 969 968 970 970 970 968 969 969

0105 Pearson r .314 .357 .223 0 .276 .297 .263 .265 .246 .238 .187 .340 .314 .292

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 980 980 975 976 976 975 969 968 970 970 970 968 969 969

0106 Pearson r .171 .211 .303 0 .246 .243 .230 .252 .271 .189 .094 .250 .181 .302



p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .003 .000 .000 .000

N 979 979 975 976 976 975 969 968 970 970 970 968 969 969

0107 Pearson r .226 .276 .219 0 .227 .214 .228 .303 .257 .287 .142 .277 .321 .383

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 979 979 975 976 976 975 969 968 970 970 970 968 969 969

0201 Pearson r .180 .204 .296 0 .209 .309 .328 .282 .129 .055 .164 .228 .195 .159

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .086 .000 .000 .000 .000

N 987 986 979 980 980 979 972 971 975 975 975 972 973 973

0202 Pearson r .282 .249 .336 0 .277 .400 .399 .355 .153 .070 .208 .259 .217 .161

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .029 .000 .000 .000 .000

N 987 986 979 980 980 979 972 971 975 975 975 972 973 973

0203 Pearson r .291 .254 .354 0 .304 .394 .413 .373 .164 .085 .214 .267 .253 .163

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .008 .000 .000 .000 .000

N 987 986 979 980 980 979 972 971 975 975 975 972 973 973

0204 Pearson r .278 .220 .329 0 .270 .381 .397 .320 .135 .014 .220 .247 .220 .156

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .659 .000 .000 .000 .000

N 986 986 978 979 979 978 971 970 975 975 975 972 973 973

0205 Pearson r .255 .196 .364 0 .277 .416 .420 .363 .149 .083 .203 .254 .238 .195

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .009 .000 .000 .000 .000

N 986 986 978 979 979 978 971 970 975 975 975 972 973 973

0301 Pearson r .432 .397 .337 0 .309 .364 .366 .382 .218 .185 .198 .300 .264 .258

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 987 986 979 980 980 979 972 971 974 974 974 971 972 972

0302 Pearson r .632 .657 .175 0 .298 .250 .248 .292 .248 .208 .154 .377 .294 .270

p value .000 .000 .000 .001 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 987 986 979 980 980 979 972 971 974 974 974 971 972 972

0303 Pearson r 1.000 .616 .206 0 .329 .288 .285 .370 .257 .236 .165 .380 .281 .255

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 987 986 979 980 980 979 972 971 974 974 974 971 972 972

0304 Pearson r .616 1.000 .183 0 .322 .270 .280 .355 .274 .268 .143 .458 .324 .373

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 986 986 978 979 979 978 971 970 974 974 974 971 972 972

0401 Pearson r .206 .183 1.000 1 .403 .493 .458 .348 .257 .163 .231 .241 .223 .181

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 979 978 979 979 979 978 971 970 972 972 972 969 970 970

0402 Pearson r .171 .167 .581 1 .376 .452 .390 .287 .253 .100 .146 .192 .112 .126

p value .000 .000 .000 .000 .000 .000 .000 .000 .002 .000 .000 .000 .000

N 980 979 979 980 980 979 972 971 973 973 973 970 971 971

0403 Pearson r .329 .322 .403 0 1.000 .518 .462 .415 .271 .213 .150 .296 .215 .248

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 980 979 979 980 980 979 972 971 973 973 973 970 971 971

0404 Pearson r .288 .270 .493 0 .518 1.000 .608 .411 .238 .126 .217 .301 .239 .232

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 979 978 978 979 979 979 972 971 973 973 973 970 971 971

0405 Pearson r .285 .280 .458 0 .462 .608 1.000 .492 .236 .128 .268 .308 .275 .282

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000



N 972 971 971 972 972 972 972 971 966 966 966 964 965 965

0406 Pearson r .370 .355 .348 0 .415 .411 .492 1.000 .287 .258 .188 .358 .308 .395

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 971 970 970 971 971 971 971 971 965 965 965 964 964 964

0501 Pearson r .257 .274 .257 0 .271 .238 .236 .287 1.000 .541 .255 .386 .311 .363

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 974 974 972 973 973 973 966 965 975 975 975 972 973 973

0502 Pearson r .236 .268 .163 0 .213 .126 .128 .258 .541 1.000 .208 .311 .244 .357

p value .000 .000 .000 .002 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 974 974 972 973 973 973 966 965 975 975 975 972 973 973

0503 Pearson r .165 .143 .231 0 .150 .217 .268 .188 .255 .208 1.000 .398 .316 .186

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 974 974 972 973 973 973 966 965 975 975 975 972 973 973

0504 Pearson r .380 .458 .241 0 .296 .301 .308 .358 .386 .311 .398 1.000 .506 .459

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 971 971 969 970 970 970 964 964 972 972 972 972 972 972

0505 Pearson r .281 .324 .223 0 .215 .239 .275 .308 .311 .244 .316 .506 1.000 .429

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 972 972 970 971 971 971 965 964 973 973 973 972 973 973

0506 Pearson r .255 .373 .181 0 .248 .232 .282 .395 .363 .357 .186 .459 .429 1.000

p value .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

N 972 972 970 971 971 971 965 964 973 973 973 972 973 973

Role Delineation Study/ Practice Analysis, 6th...

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