Fillable 2020 Pta Application Packet Fillable (City of Oakland)

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2020 Pta Application Packet Fillable (City of Oakland)

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Physical Therapist Assistant
Application Packet
Accreditation Statement
Graduation from a physical therapist assistant education program accredited by the Commission on Accreditation in Physical
Therapy Education (CAPTE), 1111 North Fairfax Street, Alexandria, VA 22314; phone; 703-706-3245;
(accreditation@apta.org) is necessary for eligibility to sit for the licensure examination, which is required in all states.
Shasta College is seeking accreditation of a new physical therapist assistant education program from CAPTE. The program is
planning to submit an Application for Candidacy, which is the formal application required in the pre-accreditation stage, on
June 1, 2020. Submission of this document does not assure that the program will be granted Candidate for Accreditation status.
Achievement of Candidate for Accreditation status is required prior to implementation of the professional/technical phase of the
program; therefore, no students may be enrolled in professional/technical courses until Candidate for Accreditation status has
been achieved. Further, though achievement of Candidate for Accreditation status signifies satisfactory progress toward
accreditation, it does not assure that the program will be granted accreditation.
*When you submit your application packet and all of the supporting documents, all forms must be in a sealed
manila envelope!
SHASTA COLLEGE HEALTH SCIENCES AND UNIVERSITY PROGRAMS
PHYSICAL THERAPIST ASSISTANT (PTA) PROGRAM
2020 APPLICATION PACKET
Application Packet Check-Off List
NAME: ________________________________________________________________________________________ID#:______________
(Last) (First) (MI)
Physical Therapist Assistant application packets for the 2020 filing period will be accepted from Tuesday, September 15, 2020, through
4:00pm on Thursday, October 1, 2020 at the Shasta College Health Sciences Division office. Mailed applications must be postmarked by
October 1, 2020. Please note: All packets turned in or postmarked on a given day will receive a randomized log-in number.
PACKETS WILL NOT BE ACCEPTED OUTSIDE OF THE APPLICATION PERIOD
COLLECT THE OFFICIAL DOCUMENTS REQUIRED AND SUBMIT WITH APPLICATION IN A SEALED ENVELOPE.
Additional documents will not be accepted after submission of the application packet.
Mail or hand deliver to: Shasta College Health Sciences Division, 1400 Market Street, Suite 8204, Redding, CA 96001
COMPLETED/ENCLOSED:
YES NO
Shasta College Application – every applicant must have a new admissions application on file at the Office of Admissions &
Records prior to turning in this packet. A new online admission application must be submitted no earlier than January 1, 2020.
Do this step even if you have previously attended and/or applied to Shasta College. A link to the online application can be
found on the shastacollege.edu website under Admissions – Apply for Admission, or by going directly to this webpage:
www.shastacollege.edu/apply and clicking the link for “New Students”.
Valid E-mail Address must be included. (Lack of an email address may disqualify applicant.)
Shasta College Physical Therapist Assistant Program Application Check List (this form, signed).
Shasta College Physical Therapist Assistant Program Application (signed).
OFFICIAL* High School Transcript showing the date of graduation, official transcript for completion of California High School
Proficiency Examination (CHSPE) or HISET exam, or official transcript of G.E.D test results or certificate. Official high school
transcript, official CHSPE or HISET, or official transcript of G.E.D test results are not necessary if applicant has a post-
secondary degree and submits the official College Transcript showing the conferred degree.
OFFICIAL* College Transcript from all colleges ever attended where work was attempted or classes were completed. If general
education or prerequisite courses were not taken at Shasta College, please include course descriptions/syllabi from the other
college(s) in your application packet.
NOTE: It is not necessary to submit an official Shasta College transcript; a transcript of your Shasta College courses will be
obtained from the Admissions & Records Office and made an official part of your application packet.
NOTE: All other College and/or high school records that may already be on file with the Shasta College Admissions & Records
Office cannot be used for this application packet. You must resubmit all college and/or high school records with the initial
application packet.
*OFFICIAL RECORDS are those which have been received from another educational institution in a sealed envelope and remain
unopened. DO NOT OPEN. If an envelope has been opened (seal broken) prior to arriving at Shasta College, it cannot be
accepted for the purpose of admission to the Physical Therapist Assistant.
Application Immunizations Documentation Check List form (signed) and required immunization documentation.
If applicable, Request an Appeal Form
Failure to follow any instructions or failure to include all required documents may result in disqualification of your Application. Once
an Application packet has been submitted, all materials become the property of Shasta College and cannot be returned to the student.
Student Signature: ______________________________________________ Date: ________________________
SHASTA COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM
2020 APPLICATION
PLEASE PRINT IN INK APPLICATION PACKET FILING DEADLINE: 4pm October 1, 2020
NAME (Last, First, MI.):
BIRTHDATE:
ALL OTHER NAMES UNDER WHICH YOU HAVE BEEN KNOWN:
STUDENT ID#:
E-MAIL (REQUIRED):
TELEPHONE:
ALT. PHONE:
CURRENT ADDRESS:
Street City State Zip
NAME AND LOCATION OF HIGH SCHOOL LAST ATTENDED:
_________________________________________________________________________________________________________________
HIGH SCHOOL GRADUATE: ( ) YES ( ) NO EQUIVALENT: ( ) G.E.D. ( ) PROFICIENCY ( ) COLLEGE DEGREE
ARE YOU A PREVIOUSLY QUALIFIED APPLICANT? ( ) YES ( ) NO If so, in what year(s) did you apply? _____________________________
WILL YOU BE SUBMITTING AN UPDATED TRANSCRIPT? ( ) YES ( ) NO, PLEASE USE MY PREVIOUSLY SUBMITTED TRANSCRIPT(S)
LIST ALL COLLEGES AND UNIVERSITIES ATTENDED, INCLUDING SHASTA COLLEGE (Use additional sheet if needed)
NAME OF COLLEGE
LOCATION
UNITS COMPLETED
(indicate Quarter or Semester)
DATES ATTENDED
FROM/TO
DEGREE
Q
S
Q
S S
Q
S
OFFICIAL high school and/or college transcripts of attempted/completed course work must be enclosed in the application packet.
Prerequisite courses may be in-progress when applying to the program. If prerequisites were completed and were not taken at Shasta
College, please attach course descriptions of pre-requisite courses from college attended. *Anatomy and Physiology must have been
completed within last 7 years.
Indicate one of the following:
PREREQUISITE
COURSES
NAME OF COURSE(S)
NAME OF COLLEGE
COMPLETED
Semester &
Year
Course
In-Progress
GRADE
ANAT 1: Human
Anatomy*
PHY 1: Physiology*
HEOC 11: Medical
Terminology
HEOC 1: Introduction
to Physical Therapy
□ My Anatomy and Physiology have been completed outside the 7 year recency requirements. I have attached a request for
appeal with supporting documentation.
By reading the Shasta College Physical Therapist Assistant Application & Enrollment Process information on the Health Sciences
webpage, I hereby acknowledge that the failure to follow application procedures or omission of required materials will result in
disqualification of my application packet.
Signature of Applicant ________________________________________________________ Date __________________________________
Health Sciences & University Programs
Application Immunizations Documentation Checklist
Last Reviewed & Revised 2/6/2020
Page 1 of 2
Name ______________________________ Shasta College ID #___________________
Date: ______________________________
Directions: Complete all the sections below and submit this form and copies of all of your immunization documentation in your
application packet.
Documentation: Immunity to infections may be documented by either vaccine administration or a positive titer. Vaccines and titers
offer the most objective documentation and protection for the student and institution. You can obtain official immunization
documentation from health departments, military records, medical offices, or school records.
Please record dates of any immunizations from your official immunization record on this form. You need to keep any originals for
your own records. (This form is a reporting document for Shasta College Health Sciences -- Not intended to be an official record).
Tetanus, Diphtheria, Pertussis (TDaP) - must show documentation of either:
A. One-time dose of TDaP (includes pertussis) required for all Healthcare
Personnel younger than age 65.
OR
Date ___________________
B. Subsequent Td booster every 10 years following one-time TDaP
Date ___________________
Varicella* - must show documentation of either:
A. Two doses of Varicella vaccine administered at least 4-8 weeks apart
OR
Date #1 ___________ Date #2 ___________
B. Proof of quantitative IgG titer showing positive/immune to Varicella
**If titer shows as negative OR equivocal immunity, proceed to Option 1 or 2.
Date ___________ Results ____________
**Options
You must either:
1) provide proof of having previously received the original 2-dose
vaccination series and having received one (1) booster after your
negative titer OR
2) if you have no previous records, proof of obtaining the 2-dose series after
your negative titer
Option 1: Original Series given:
Date #1 ___________ Date #2 ___________
Date of Booster: ____________________
Option 2: Series given:
Date #1 ___________ Date #2 ___________
* Note: A previous diagnosis of chickenpox is NOT accepted as proof of Varicella immunity. Must submit documentation of either A or B as
outlined above.
Dental Hygiene Physical Therapist Assistant Vocational Nursing
Health Sciences & University Programs
Application Immunizations Documentation Checklist
Last Reviewed & Revised 2/6/2020
Page 2 of 2
Measles, Mumps, Rubella (MMR) - must show documentation of either:
A. Two doses of MMR vaccine administered at least 4-weeks apart
OR
Date #1 ___________ Date #2 ___________
B. Proof of quantitative IgG titer showing positive/immune to Measles,
Mumps, and Rubella
**If titer shows as negative OR equivocal immunity, proceed to Option 1 or 2.
Measles: Date ________ Result __________
Mumps: Date ________ Result __________
Rubella: Date ________ Result __________
**Options
You must either:
2) provide proof of having previously received the original 2-dose
vaccination series and having received one (1) booster after your
negative titer OR
2) if you have no previous records, proof of obtaining the 2-dose series after
your negative titer
Option 1: Original Series given:
Date #1 ___________ Date #2 ___________
Date of Booster: ____________________
Option 2: Series given:
Date #1 ___________ Date #2 ___________
Hepatitis B - must show documentation of:
A.
Proof of Hepatitis B AB [antibody] Surface IgG titer (NOT AG [antigen])
showing positive/immune
*If titer shows as non-reactive/negative immunity, proceed to Steps 1 & 2
Date ____________ Results ___________
Step 1: Receive at least one (1) booster of the vaccine. Discuss with your
healthcare provider if your titer results indicate that you may need multiple
boosters or to repeat the entire series. PLEASE START THIS IMMEDIATELY.
• CDC standard recommendations are for series to be given at 0, 1, and 6 months.
• CDC minimum requirements allow for series to be given at 0, 1, and 4 months.
Step 2: Obtain a new titer for Hepatitis B AB [antibody], NOT Hep B AG
[antigen]) at least 4 weeks after the final booster/dose and submit the results
showing positive/immune
Date # 1 ___________________________
Date # 2 ___________________________
Date # 3 ___________________________
Date ____________ Results ___________
For Health Sciences Division Use Only:
Date Received:
Immunization official documentation verified by:
Notes:
Health Sciences & University Programs
Physical Therapist Assistant – Request for Appeal
Work Experience Verification Form
Last Reviewed 3/05/2020
Page 1 of 1
Physical Therapist Assistant
Request for Appeal
Work Experience Verification Form
In order to appeal the recency requirement for the Anatomy and Physiology
prerequisites, applicants must be working in direct patient or client contact in a
healthcare or exercise profession that utilizes the principles of Anatomy and
Physiology. Work experience must be at least 500 hours within the last two
(2) years
In order to prove work experience that utilizes the principles of Anatomy and
Physiology, the applicants must complete the work verification statement
below regarding their work experience in direct patient or client contact in a
healthcare or exercise profession.
For work experience hours accumulated from more than one employer,
a separate form must be submitted from each employer.
This verifies that ______________________ was an employee of ________________
(Name of Employee) (Name of Firm, Agency, etc)
____________________________________ _______________________________
(Address of Firm, Agency, etc) (Phone Number)
From _______________ to _______________ for a total of at least 500 hours.
Employer/Supervisor’s Signature: ______________________ Date: ______________
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Completed 17 January 2021

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