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FORM1PTObservationv2

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FORM1PTObservationv2 Powered By Docstoc
					FORM 1 - PHYSICAL THERAPY OBSERVATION for
                                                                                         (Applicant’s name)

STATUS OF EXPERIENCE:            Planned                             On-going                         Completed

VERIFICATION STATUS                          Verified                                       Not yet verified

NAME of FACILITY:
ADDRESS:




(Street, City, State, Zip, Country)

Is this Physical Therapist also a Reference?       YES         NO

Name of Physical Therapist:

PT License Number:                                                   State of PT License:

PT PHONE:                                                            PT EMAIL:
        TYPE of EXPERIENCE:                                   Dates                                      Total Hours
Inpatient / Outpatient / Community



PAID or VOLUNTEER EXPERIENCE?               Paid         Volunteer

                           SETTING                                      PHYSICAL THERAPY SPECIALITY AREAS(s) OBSERVED

                                                                                                                       # hours
Acute Care                                                           Cardiovascular and Pulmonary

Rehab/Sub-Acute Rehab                                                Clinical Electrophysiology

Extended Care Facility                                               Geriatrics

Outpatient Clinic (Private Practice)                                 Neurology

School/Pre-school                                                    Orthopedics

Wellness/Prevention/Fitness                                          Pediatrics

Industrial/Occupational Health                                       Sports

Other (describe)                                                     Women’s Health

                                                                     Other (Describe):




                                               UNIVERSITY OF THE INCARNATE WORD
                                          4301 Broadway, San Antonio, TX, 78209
                                      210-283-6477           www.uiw.edu/PhysicalTherapy

				
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