Fillable CCC PTA ObservationLog

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CCC PTA ObservationLog

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Clovis Community College PTA Observation Log
Applicant Name ________________________________ *May require more than one sheet to log all required hours*
*NOTE: Only hours supervised by a licensed Physical Therapist/Assistant will be considered
Facility Name, Address, and
phone number
Date of
experience
Note:
Observation
Work
Volunteer
Time
Beginning and ending
time with total number of
hours. *Do not include breaks or
time with other disciplines*
Setting
(OP, Acute,
inpatient
rehab,
nursing
home, VA,
school,
home
health,
other
specify)
Primary
Patient
Population
(Adult,
pediatrics,
geriatrics,
other)
Printed name and
Signature PT or PTA
observing
License
number and
state of PT or
PTA
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CCC PTA ObservationLog

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Completed 15 November 2019

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