Document Sample

                                    Fall 2012 APPLICATION
                                    Physical Therapist Assistant Program
                                    for the Current UE Student
Date of Application

 Application Deadline: June 1, 2012. Please limit your information to the space provided. Application must be

1. Name

Last                        First                         Middle                           Maiden

2. Gender
Male          Female

3. Permanent Address

Street                                      City                                   State             Zip

4. Permanent Telephone (include area code)

5. Social Security Number

6. Birth Date (include month, date, year)

7. Marital Status

8. Current Mailing Address

Street                                      City                                  State             Zip

9. Current Telephone (include area code)

10. E-mail Address
11. U.S. Citizen?
Yes             No

Permanent U.S. Resident?
Yes            No

Country of Citizenship

12. Race (optional)
Do you consider yourself to be Hispanic/Latino?
Yes             No

Please select one or more of the following categories to describe yourself
African American or Black
American Indian or Alaskan Native
Caucasian or White
Native Hawaiian or other Pacific Islander

13. High school attended

Name                                           City                          State        Year of Graduation

 SAT Scores

Verbal                                 Math                                     Written

ACT Score

14. List all undergraduate schools attended.

Institution attended

Dates of attendance

Institution attended

Dates of attendance

Institution attended

Dates of attendance

Degree(s) attained
15. List honors or special awards received while attending high school.


16. List honors or special awards received while attending college.


17. List extracurricular, community or volunteer activities, unrelated to physical therapy, in which you have
    participated while in the last five years. Include activity and dates.

         Activity                                                            Dates

18. List all employment. Include place of employment, hours per week, and dates.

     Place of Employment                                               Hours/Week          Dates

19. List your observation, volunteer or employment activities which were supervised by a physical therapist or
    physical therapist assistant. (A minimum of 20 hours in at least two different settings is required.)

                                                           Types of Treatment        Total       Volunteer or
     Dates           Place                                     Observed              Hours        Employment

20. Essay
Please describe in detail what you have done to explore the role of the physical therapist assistant and how it
differs from that of a physical therapist. Other than the desire to help people, why do you want to be a physical
therapist assistant? Please type your answer to the essay question on a separate sheet of paper and attach it to
the application. The essay should be double-spaced and limited to two single-side pages with one inch margins
top, bottom and sides in 12-point type. Please sign the completed essay. Plagiarism is considered a serious
offense at the University of Evansville. If it is determined that your essay has been plagiarized or
purchased, you will be eliminated from consideration for the program.


The following standards specify the essential functions that the faculty considers necessary for completing the
physical therapist assistant program and entering clinical practice. To function as a physical therapist assistant,
individuals must be able to meet certain physical, cognitive, and social emotional standards. The skills
identified must be performed in the classroom and clinical settings. Students must be able to meet these
minimum standards, with or without reasonable accommodation, to successfully complete programmatic
requirements. Prospective students who indicate that they can complete these essential functions, with or
without reasonable accommodation, are not required to disclose specific information regarding their disability
prior to an admission decision. Reasonable accommodation does not imply that students with disabilities will
be exempt from certain tasks; it does mean that the faculty will work with students to find strategies by which
they can complete program requirements.

Any applicant with questions about these requirements is encouraged to discuss the issue with the Dean of
Students. Prospective students who are unable to complete these tasks are ineligible for consideration for
admission. Students with disabilities who are admitted to the physical therapy programs must request submit a
written request to the Chair of the Department of Physical Therapy for requesting reasonable accommodation.
If a student is unable to complete an essential task with accommodation, or the accommodation needed is not
reasonable and would cause undue hardship to the University, or if the student's inability to fulfill the task
would create a significant risk of harm to the student or others, the offer of admission will be withdrawn.

Observation requires the use of vision, hearing, and other sensory modalities. Students must be able to observe
lectures, laboratories, and other demonstrations. Students are required to observe patients accurately and
interpret patient movement, skin conditions, changes in appearance, and identify safety hazards.

Students are expected to be able to communicate effectively and sensitively with patients in English and possess
the ability to perceive nonverbal communication. Additionally, students must be able to communicate in oral
and written forms with faculty, peers, other health care professionals, and caregivers.

Students must possess gross and fine motor abilities to provide safe and effective physical therapy care.
Students must have sufficient motor function to assess patients through the use of palpation, auscultation,
percussion, and other measurement activities. Students must be able to execute motor movements to provide
physical therapy interventions such as positioning a patient, the strength to stand and ambulate with a patient
and to perform manual mobilization techniques. Students must also possess the mobility and strength necessary
to provide emergency care including cardiopulmonary resuscitation.

Intellectual-Conceptual Integrative and Quantitative Abilities
To effectively solve problems, students must be able to measure, calculate, reason, analyze, integrate, and
synthesize information. Problem solving and identifying the physical therapy diagnosis through review of
specific tests and measures is necessary. Good judgment, the ability to prioritize and make decisions, and the
ability to measure and record patient outcomes is essential.

Behavioral/Social Skills and Professionalism
Students must possess honesty, integrity, flexibility, motivation, and empathy. Emotional health is required so
that the student has full use of his/her intellectual abilities and is able to complete aspects of patient
management related to implementation of the plan of care. Students must be able to tolerate physically
challenging workloads and function effectively under stress. The ability to accept constructive feedback and
modify behaviors as necessary is also required.

Health Status
Students must demonstrate overall health and maintain their personal appearance and hygiene to participate in
classroom and clinical education experiences. Students must follow all standards and policies in the Physical
Therapist Assistant Handbook, University Student Handbook and the Clinical Education Manual. These
documents are available for review.

21. Have you ever been convicted of, plead guilty to or nolo contendre to any offense, misdemeanor or felony in
    any state or do you have charges pending for which you could be convicted (except for minor traffic violations
    resulting in fines)? If yes, please explain in an attached letter.

Yes                  No

  A felony conviction or a conviction for drug or alcohol abuse may preclude an individual from being
  able to complete clinical course work required for graduation and/or secure a license to practice
  physical therapy. Individuals affected by this should contact the physical therapy board in the state in
  which they wish to practice to seek advice.

My signature verifies that all information in this application is complete and accurate. I understand that concealment of
relevant information or falsification of information may lead to my not being selected for the Physical Therapist Assistant
Program or removal from the program at any time in the future.

Signature                                                                               Date

  Applicants should submit application materials (with a stamp from Student Accounts confirming that the $10.00
 application fee has been paid) to the Department of Physical Therapy in GH 233. Application deadline: June 1,
 1. PTA program application
 2. College transcripts from all universities from which college credit was received

 The University of Evansville reserves the right to exercise judgment in the selection process for the Physical
 Therapist Assistant program. All decisions are final.

 The University of Evansville operates under a non-discriminatory policy with regard to race, color, creed or
 religion, national origin, gender, sexual orientation, age or disability.

For Student Accounts Use

Name____________________________                      Student ID____________              Date____________________

Term: Fall 2012

PTA-$10.00 APPLICATION FEE PAID (ACCT # 10-01-101000-40030)

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