Fill - Free fillable Clinical Handbook (Mohave Community College) PDF form

Clinical Handbook

2020-21 Academic Year

Mohave Community College * 1977 Acoma Blvd, West * Lake Havasu City, AZ 86403 * PTA Program Support 928-505-3351

Revised 6/29/2020 Page 2 of 20

Physical Therapist Assistant Program

Contents

Anti-Discrimination Policy Statement .................................................................................................................................. 3

Program Contact Information ............................................................................................................................................... 3

Frequently Called Numbers .................................................................................................................................................. 3

The Physical Therapist Assistant .......................................................................................................................................... 3

Program Philosophy ............................................................................................................................................................. 4

PTA Program Mission Statement ......................................................................................................................................... 5

PTA Program Vision Statement ............................................................................................................................................ 5

Campus Safety ...................................................................................................................................................................... 5

Americans With Disabilities Act (ADA) Statement ............................................................................................................. 5

PTA Student Graduate Outcomes ......................................................................................................................................... 5

PTA Program Goals .............................................................................................................................................................. 6

PTA Student Responsibilities ............................................................................................................................................... 6

Attitude ................................................................................................................................................................................. 6

Conduct ................................................................................................................................................................................ 7

Clinical Dress Standards ....................................................................................................................................................... 7

Complaint Procedures For External Community .................................................................................................................. 8

Student Safety During Off-Campus Educational Experiences .............................................................................................. 8

Drug-Free Schools And College Prevention Program Commitment ..................................................................................... 8

Clinical Education Courses ................................................................................................................................................... 8

PTA 206, PTA 280 And PTA 290 ........................................................................................................................................ 8

Absence During Clinical Rotation ................................................................................................................................

........ 9

Clinical Work Expectations .................................................................................................................................................. 9

Informed Consent ............................................................................................................................................................... 10

Records Required For Clinical Rotations............................................................................................................................ 11

Injury And Emergency Procedures ..................................................................................................................................... 12

Clinical Practice Settings .................................................................................................................................................... 12

Clinical Competencies ........................................................................................................................................................ 13

HIPAA ................................................................................................................................................................................ 16

Student Clinical Education Requirements For Communication And Documentation ......................................................... 16

Clinical Instructor Guidelines For Clinical Education For Communication And Documentation....................................... 17

Clinical Faculty Qualifications & Development ................................................................................................................. 17

Getting Started With The APTA Learning Center And CPI Web ....................................................................................... 17

Appendices ......................................................................................................................................................................... 18

Counseling Offense Form ................................................................................................................................................... 19

Program Complaint Form ................................................................................................................................................... 20

Mohave Community College * 1977 Acoma Blvd, West * Lake Havasu City, AZ 86403 * PTA Program Support 928-505-3351

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Physical Therapist Assistant Program

Anti-Discrimination Policy Statement

Mohave Community College does not discriminate on the basis of race, color, ethnicity, national origin, gender,

sex, age, religion, gender identity, gender expression, disability, or sexual orientation in its educational programs

and activities or employment practices.

Discrimination includes harassment, which includes a wide range of abusive and humiliating verbal or physical behaviors

that are directed against a particular person or persons because of one of the above-named qualities. This includes creating

a “hostile environment” where the conduct is sufficiently severe or pervasive to alter the conditions of the person’s

employment or educational experience at the College. Members of the College community have a responsibility to report

discrimination and those in supervisory roles are obligated to take action to correct it. Any person found to have violated

this anti-discrimination policy will be subject to appropriate disciplinary action.

For further information on campus safety or a complete list of the Title IX team, visit the Campus Safety

webpage.

Questions or complaints regarding Title IX may be referred to:

Danette Bristle (Title IX Coordinator)

Accreditation Liaison/Compliance Officer

3400 Highway 95, Bullhead City, AZ 86442

dbristle@mohave.edu

928.704.9480 (w), 928.542.6920 (m)

Program Contact Information

Please contact one of the following individuals or the program website if you have additional questions about the PTA

program:

Liz Briere PT, DPT, Program Director

Phone: (928) 505-3347

Email: ebriere@mohave.edu

Tamra Coleman, PT, DPT, OCS, COMT, ACCE/Resident Faculty

Phone: (928) 302-5323

Email: tcoleman@mohave.edu

Jennine Ramirez, Program Secretary

Phone: (928) 505-3351

Email: jramirez@mohave.edu

PTA Program Website: http://www.mohave.edu/pta

Academic Advising Can Be Reached Toll Free at:

MCC Connect - 866-664-2832

Frequently Called Numbers

MCC Connect 866-664-2832

Library 928-505-3309

PTA Program Office 928-505-3351

PTA Program Fax 928-453-1836

The Physical Therapist Assistant

The Physical Therapist Assistant (PTA) is a skilled health care worker who assists the Physical Therapist in providing

physical therapy treatment interventions to patients and/or clients in a variety of practice settings. Duties of the PTA are

varied and may include, but are not limited to, the rehabilitation of adult and pediatric clients with orthopedic, neurological,

traumatic injuries, and various medical conditions through the application of physical modalities, exercise programs, gait

training, functional activities and patient education.

Mohave Community College * 1977 Acoma Blvd, West * Lake Havasu City, AZ 86403 * PTA Program Support 928-505-3351

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Physical Therapist Assistant Program

The PTA graduate must obtain a certificate/license to practice as a PTA. Graduates are required to contact the physical

therapy regulatory agency for that state regarding licensure/certificate requirements.

This MCC PTA program is committed to a high standard of educational excellence while promoting learner responsibility,

effective communication, critical thinking, and collaboration. We strive to educate entry level PTA generalists that adhere

to professional, ethical, and legal guidelines of the profession to serve our communities. We strive for excellence in all

aspects of student education. Student education will be focused on theory, knowledge, and clinical skills essential to the

entry level PTA.

The curriculum is designed for the optimal use of technical innovation, hands-on learning, and thorough practical clinical

education. This structure drives our emphasis on technology and communication to facilitate learning in the classroom and

the clinic. Graduates will meet the diverse needs of employers and the community while providing high quality patient care

under the direction and supervision of a Physical Therapist.

The PTA program provides students a curriculum consistent with the guidelines of The Higher Learning Commission of

the North-Central Association of Colleges and Schools, the Commission on Accreditation in Physical Therapy Education

(CAPTE), and the Normative Model of Physical Therapist Assistant Education: version 2007.

The PTA program curriculum is highly structured, involving classroom, web-enhanced courses, lab and clinical work as

well as a considerable amount of personal study. The program format is a full-time day program. However, dependent on

program needs, occasionally an evening course may need to be offered. Program faculty will assess competency in skills

and knowledge gained in the classroom and lab through practical exams prior to your use of these skills on patients during

clinical affiliations. Expectations of the Program include, but are not limited to:

 Being available and on time for class or clinic as scheduled

 Preparing in advance for class/lab activities

 Providing your own transportation to assigned clinical sites

 Providing for your own housing during assigned clinical affiliations

 Demonstrating professional behavior at all time

Upon successful completion of the PTA educational experience at MCC you will be awarded an Associate in Applied

Science (AAS) degree and will be eligible to sit for the National Physical Therapy Examination for PTA’s. Additionally,

it is hoped that all students will participate in the college and program evaluation process by notifying the program faculty

about areas of strengths and/or needing improvement. Faculty and staff hope your time spent in PTA education is successful

and enjoyable.

Program Philosophy

We believe that physical therapy is a valuable and integral part of health care and the PTA functions as an effective member

of the health care team. The PTA requires specialized knowledge and skills and works under the direction and supervision

of a licensed Physical Therapist.

The entry level PTA should be able to practice in an ethical, legal, safe and effective manner. We, as educators, accept the

responsibility for supplying students with opportunities to learn the necessary information and inform students of clinical

practice required for state regulation and entry-level competence in the field.

Education and learning are lifelong processes and should be evidence based. In our role as faculty and health care providers,

we must model the processes of creating a learning centered environment to facilitate lifelong learning, adapting, being

flexible, and changing as the environment and culture changes in accordance with sound scientific developments in

education, instructional delivery methodology, medical science, and physical therapy practice. Likewise, it is the student’s

responsibility to fully utilize the opportunities provided by this educational program.

The choice of career is a personal decision, and having chosen a particular profession, the individual must assume the

profession’s inherent responsibilities and adhere to established professional ethics and standards of practice. As students

begin the process of becoming PTA’s, they must constantly learn and adapt to different situations, patients, treatment

techniques, disease processes and other conditions.

Mohave Community College * 1977 Acoma Blvd, West * Lake Havasu City, AZ 86403 * PTA Program Support 928-505-3351

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Physical Therapist Assistant Program

PTA Program Mission Statement

The mission of Mohave Community College PTA Program is to be a learning-centered institution to foster the professional

and academic development of the PTA program to better serve the students and the community. The Mohave Community

College PTA Program will provide an environment for educational excellence for students to become competent and

professional Physical Therapist Assistants. Students will become aware of the world of physical therapy as they develop

the structured skill set to perform as a Physical Therapist Assistant under the supervision of a licensed Physical Therapist.

The students of the PTA program will develop into safe, competent healthcare practitioners, thus providing a much-needed

service to Mohave County, surrounding communities and states.

PTA Program Vision Statement

The Mohave Community College PTA Program strives to be a leader in Physical Therapist Assistant education in order to

better serve the community and meet the demands of the healthcare industry.

Campus Safety

As required by the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, MCC files a

statistical report each year on all criminal activity that has occurred on and around MCC campuses. In addition, the Clery

Act requires MCC to disclose statistics on crimes committed on and near its campuses for the previous three years. As the

report indicates, MCC campuses have been exceptionally safe in recent years. MCC has also implemented a college-wide

crisis plan, as well as plans for each campus that outline procedures for how MCC administrators, staff, and faculty should

deal with potential emergencies. MCC takes additional steps to ensure student safety by employing night security guards

and part-time administrators on each campus to handle any emergency situations that may arise for faculty or students

between the hours of 5 p.m. and 10 p.m. For more information, see the Campus Safety webpage and

MCC Crimes

Statistics Report.

Americans with Disabilities Act (ADA) Statement

Mohave Community College strives to facilitate, within reason, appropriate resources, services and auxiliary aids to allow

each qualified person with a documented disability equitable access to educational programs, social experiences, and

career opportunities. The Compliance Officer and Chief Human Resources Officer shall act as ADA coordinators for the

College to oversee compliance in the areas of facilities, student accommodations, and employment practices.

PTA Student Graduate Outcomes

Graduates of the Physical Therapist Assistant Program will be able to:

1. Demonstrate safe and effective application of treatment techniques established within the plan of care.

a. Review and understand plan of care written by licensed PT prior to patient intervention.

b. Provide safe treatment within the scope of the plan of care written by the licensed PT.

c. Describe the rational of treatment interventions to achieve the goals and outcomes as described in the plan

of care.

2. Demonstrate effective oral, written, and nonverbal communication in a culturally competent manner with patients,

their families, colleagues, and the public.

a. Effectively communicate with patients and family in order to provide clear, concise instructions to ensure

safety and achieve functional outcomes.

b. Communicate with members of the healthcare team in a professional and timely manner.

c. Participate in community and/or physical therapy professional events.

d. Demonstrate understanding of cultural competence in healthcare.

3. Demonstrate their ability to contribute as a functional team member within the physical therapy profession.

a. Understand the role of the PTA in patient care and team meetings.

b. Interact with members of the healthcare team.

c. Manage patient caseload, documentation, and billing within the allotted time.

4. Demonstrate safe, effective, moral, ethical and legal behaviors within the scope of physical therapy.

a. Understands legal and ethical standards as well as state practice acts.

b. Utilize APTA’s “Guide for Conduct of the Physical Therapist Assistant” as the standard for

professionalism and conduct.

Mohave Community College * 1977 Acoma Blvd, West * Lake Havasu City, AZ 86403 * PTA Program Support 928-505-3351

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Physical Therapist Assistant Program

5. Demonstrate their role in physical therapy by implementing a comprehensive treatment plan to promote optimal

patient outcomes.

a. Effectively progresses a patient through the plan of care written by licensed PT.

b. Demonstrates critical thinking when working with patients who have adverse response to PT

interventions.

c. Promotes active involvement by the patient in his or her care.

6. Recognize the relationship between concepts leaned from liberal arts and basic science coursework and physical

therapy knowledge and skills.

a. Utilizes reading, writing, and communication skills with patient care.

b. Incorporates human physiology and anatomy with the application of physical therapy interventions.

7. Demonstrate clinical skills necessary to practice at the entry level for the physical therapist assistant prior to

graduation.

a. Describe accurate and timely information for billing and payment purposes.

b. Demonstrate competence in implementing selected components of interventions identified in the plan of

care established by the PT.

c. Demonstrates the application of interventions and modalities in a technically competent manner within

the plan of care.

d. Identifies adverse response in patient care and responds in an appropriate and safe manner.

PTA Program Goals

1. Develop and deliver integrated academic program leading to license or certificate to practice as an entry level

physical therapist assistant.

2. Provides curriculum consistent with guidelines with CAPTE and the normative model of physical therapist assistant

education for entry level physical therapist assistant.

3. Utilizes current, evidence-based curriculum based upon input from the advisory committee, academic faculty, and

clinical instructors.

4. Provide an academic setting that facilitates program graduates to enter the physical therapy profession in a timely

fashion and in adherence to accrediting body’s criteria.

5. Promotes faculty involvement with continuing personal and professional development through life-long learning

opportunities and membership with professional organizations.

6. Promotes faculty participation with community events that promote professional and critical development.

PTA Student Responsibilities

It is important that you be well informed about your academic program. To accomplish this task, you should maintain the

following items in your files (electronic copies will be permitted):

1. MCC’s current catalog and student handbook

2. MCC’s schedule for each semester you are enrolled

3. Program Orientation Manual

All students at MCC are subject to the policies of the college as found in the MCC Catalog, MCC Student Handbook and

PTA Program Student Handbook. The PTA program documents have been developed as additional information resources

for you. It is also the student’s responsibility to hold and maintain:

1. Valid Driver’s License

2. Means of transportation

3. Maintain current clinical records

4. Technology to access learning management system and educational resources

Attitude

Each Physical Therapist Assistant represents the entire profession of physical therapy to the client/patient being served. The

PTA’s expressed or demonstrated attitudes toward others, as well as toward other health professions and services are very

apt to be reflected in the subsequent attitude of the patient toward other therapists and towards health care in general.

Mohave Community College * 1977 Acoma Blvd, West * Lake Havasu City, AZ 86403 * PTA Program Support 928-505-3351

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Physical Therapist Assistant Program

Attitudes may be reflected in outward behavior such as facial expressions, actions, body language, and conversation.

Students must exhibit behaviors that reflect an attitude of openness to learning and motivation to helping others. Listed

below are some of the expected attitudes, with examples of the type of observable behavior that is desirable.

1. Honesty and Integrity - Refuses to lie, steal or deceive in any way; abides by APTA’s Standards of Practice for

Physical Therapist Assistants.

2. Punctuality - Arrives on time for class, clinics and labs; completes assignments on time. This includes having all

appropriate clinical tools available.

3. Off-Campus Scholarly Activity - Behaviors during off-campus activities are similar to on-campus. All policies

regarding student behaviors will be the same as classroom expectations. Students need to adhere to appropriate

attire as indicated by the instructor.

4. Cooperativeness - Follows established departmental protocol and procedures; demonstrates a willingness to work

well with others and is receptive to suggestions for improvement.

5. Pride in Workmanship - Strives for improvement in assignments and clinic; requests assistance when having

difficulty in attaining the specified performance standards.

6. Mature Actions - Assumes responsibility and consequences for his/her actions; accepts his/her own limitations;

strives to resolve personal conflicts. Students are liable for supplies checked out in his/her name.

7. Consideration for Others - Demonstrates appropriate verbal and nonverbal communication and thoughtful regard

for the feelings and rights of other students, faculty, staff, and clinic personnel. The PTA is a member of the health

care team and must therefore learn to cooperate with others. Being respectful and courteous with classmates is the

first step toward this goal. Students should show the proper respect and courtesy to the members of the faculty and

staff. This applies whether in the classroom, in the lab, at the clinical facility, or anywhere on campus.

8. Concern for Patients - Demonstrates by verbal and nonverbal communication that the patient comes first; refrains

from spoken remarks and/or facial expressions which could arouse undue concern, alarm, or embarrassment to the

patients; respects patient’s rights to confidentiality or personal information; refrains from referring disparagingly to

the services of another health professional in the presence of a patient. The PTA student must be prompt, courteous,

and respectful at all times. The patient’s care must always be the PTA student’s primary concern.

9. Enthusiasm - Displays initiative in class, lab and in clinical situations; volunteers to assume responsibility.

10. Ability to Accept Constructive Criticism Gracefully - Strives to improve and is not defensive but receptive to

suggestions for improvement.

11. Clinical Decorum - Student focuses conversation during class and lab on information relevant to learning. Students

should remember that lab and clinic are designed to be learning experiences. There should be no visiting in lab or

clinic that disrupts the instructor. Remember the patient hears everything. Likewise, “chatting” with classmates

can also be overheard by patients in waiting rooms and hallways. Each student is responsible for maintaining the

cleanliness of the classrooms and lab areas.

12. Loyalty - Supports with words and actions the ideals and policies of the school, the program and the profession.

13. Pride in Personal Appearance - Student maintains professional appearance and personal hygiene consistent with

the program’s guidelines.

14. Tact - Exercises discretion in words and actions to maintain good relations with patients, peers and faculty.

Conduct

The student is expected to abide by all provisions of the APTA Ethics and Professionalism, Guide for Professional

Conduct and the Standards of Ethical Conduct for the Physical Therapist Assistant published by the American Physical

Therapy Association. Students are also required to abide by the

MCC Student Code of Conduct. It is the student’s

responsibility to report changes in medical status, personal information, and/or illegal or criminal actions.

Clinical Dress Standards

Students are expected to dress appropriately and professionally during clinical education courses. Slacks with the PTA polo

shirts or requested clinical attire by the facility. Shoes must be clean and sturdy. You may be asked to wear scrubs at some

of your affiliations. Students must wear their ID badge always.

Jeans are unacceptable. T-shirts and sleeveless tops are unacceptable. Open-toed shoes and high heeled shoes are

unacceptable. Students will be sent home to change into appropriate attire.

Students in the program are expected to maintain grooming and hygiene standards consistent with the clinical workplace.

This means that:

 Hair (including facial hair): Must be clean and trim. Long hair should be pulled back and secured.

Mohave Community College * 1977 Acoma Blvd, West * Lake Havasu City, AZ 86403 * PTA Program Support 928-505-3351

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Physical Therapist Assistant Program

 Nails: Must be clean and fingertip length. False fingernails/overlays are not allowed.

 Jewelry: Should be minimal. If in doubt, don’t wear it. Stud earrings are permitted only in the ears with a maximum

of two. No earrings in the cartilage of the ear are appropriate. No loops or dangling earrings are allowed.

 Perfume/Cologne: Not allowed.

 Body odor/Breath: Must be pleasant.

 Tattoos: Visible tattoos need to be covered at all times except for when lab attire is requested.

 Body Piercings: Body piercings need to be removed or covered.

 Natural hair colorings and traditional cuts are acceptable. Extreme hair styling and colors are unacceptable.

*Please note that visible tattoos, body piercings or physical defacement from body piercings may prevent a student from

being placed at a clinical site. Clinical placement is not guaranteed and is necessary for program completion and graduation

from the PTA program.

Complaint Procedures for External Community

(Including clinical education sites, employers of graduates and the general public)

Any individual who may have a complaint regarding any aspect of the program outside of the realm of due process is

requested to follow the steps outlined below:

1. Inform the Program Director of the complaint. The Program Director will provide a complaint form to be completed

by the individual reporting the complaint. In the event that the complaint is against the Program Director, the

individual will be referred to the Associate Dean of Instruction or Campus Dean.

2. Submit the written complaint to the Program Director.

3. The Program Director will send copies of the complaint to appropriate college administrative officials as dictated

by the nature of the complaint. The college officials receiving notification of a complaint may include but are not

limited to any or all of the following: Associate Dean of Instruction, Campus Dean.

4. The Program Director will investigate the complaint and draft a written response within ten working days from the

receipt of the written complaint.

5. The written response will be reviewed with the individual who made the complaint. Any actions proposed or taken

will also be discussed with the individual who made the complaint.

6. In the event that this individual is not satisfied with the program’s response to the complaint, the matter will be

forwarded to college administrative officials for any further action deemed necessary by the college.

7. Records will be maintained electronically and will remain on file until next accreditation visit. A log of complaints

will include a disposition of the complaint as well as any action taken, if any.

8. The forms are available from program faculty.

Student Safety during Off-Campus Educational Experiences

Please refer to MCC Policies and Procedures Manual, 5.095.04 and 5.095.05 Field Trips for details.

Drug-Free Schools and College Prevention Program Commitment

Please refer to MCC Policies and Procedures Manual and/or MCC website on Drug Free Schools and Communities Act

Amendment. (Public Law 101-226, 20 U.S.C. §1145g).

Clinical Education Courses

PTA 206, PTA 280 and PTA 290

The clinical courses allow the physical therapist assistant student to apply techniques and theory learned in the lab and

lecture sessions to direct patient care in a variety of physical therapy practice settings. Patient care is provided at outlying

facilities under the direct supervision of a physical therapist or physical therapist assistant.

MCC relies on various clinical placement agencies to provide clinical experiences for our students. These sites have several

requirements to include PreCheck Background Check, valid Level 1 Fingerprint Clearance Card, physical, valid CPR card,

and proof of immunization. Upon acceptance to the Physical Therapist Assistant Program, they are responsible for obtaining

a PreCheck background check and a valid Level 1 Fingerprint Clearance Card. This information will be included in the

acceptance packet. The program will pay and arrange for the drug screening prior to clinical placement. If a student cannot

complete the program for one of the reasons stated above, students are still responsible for the debts they incurred.

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Physical Therapist Assistant Program

Professional Conduct at Clinical Site

PTA students should consistently portray a professional attitude in order to inspire the patient’s confidence. Students must

treat patients and staff with respect, courtesy and confidentiality. Students must provide the best treatment for the patient

that their skills allow, under the supervision of a licensed physical therapist.

1. Students will not be using cell phones for personal use during clinical work hours, as it disrespectful and

unprofessional. Students using cell phones for personal use while treating patients may be withdrawn from the

clinical experience and will impact progression through the PTA program.

2. Students should always introduce themselves as a Physical Therapist Assistant Student and wear their name tags.

Address others as Mr., Mrs., Dr., etc. unless directed otherwise.

3. Students should limit personal involvement with fellow staff member to “off duty” hours. Professionalism in the

facility must be maintained at all times.

4. Students should avoid loaning personal items to patients and/or running errands for patients.

5. Students should accept constructive criticism gracefully.

6. Students should inform the clinical instructor in the clinical facility of activities and location at all times, especially

when off the unit.

7. Students are responsible for providing their own transportation to and from the clinical sites.

8. Abide by the Standards of Ethical Conduct for the PTA and the Standards of Practice for Physical Therapy found

on the APTA Ethics and Professionalism website

Failure to comply with stated program policies and procedures will result in “Counseling Offense Form” documentation.

Repeated failure to comply with the stated procedures will impact progression through the PTA program.

Absence during Clinical Rotation

The clinical experience is designed to mimic the work environment. Full attendance is essential for completion of clinical

practical. The expectation is that you will be present every day you are scheduled to be at the clinical site for the duration

of the four or six-week affiliation. The four and six-week clinical agreement does not provide for any absences. Any

absence must be made up with the student, ACCE, and clinical site. Any absences must be made up through mutual

arrangement with the student and the clinical site. The academic coordinator of clinical education (ACCE) must be

informed in this event. The student must contact their clinical instructor AND the ACCE if he/she will be absent from the

clinic.

Absences greater than 10% of the required clinical hours will not be successful with the clinical practicum. Students will

be required to extend or repeat the clinical (if offered) or will receive a failing grade.

Clinical sites are contracted for the selected clinical education experiences and time frames. There is no guarantee that a

student will be allowed to make up the time in the clinic for any absences. It is in the student’s best interest to participate

fully in their clinical experiences.

Clinical Work Expectations

Break Periods/Lunch

Lunch breaks are solely at the discretion of the facility.

Conflict Resolution

In the event of conflict between the student and the Clinical Instructor, every effort should be made to solve the problem

between the Clinical Instructor and the Student. The Center Coordinator for Clinical Education (CCCE) may help to provide

direction in the problem-solving process. If the problem remains unsolved it may be necessary to involve the Academic

Coordinator for Clinical Education (ACCE). Conflicts are inevitable. Adherence to problem solving principles should allow

the appropriate resolution of most problems.

Clinical Hours

Students are expected to be at their clinical assignment until the agreed upon finish time. Students may be required to stay

later than their assigned time should the demands of patient care require extended time. Students should be given the

opportunity to make alternative travel arrangements if an extended day is required. Students are required to be at the clinical

site during the same hours as their CI. This may include weekends and/or holidays.

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Evaluation of Performance

Assessment of a student’s performance during the clinical rotation should be an ongoing process. The Clinical Instructor is

expected to guide the experience with an emphasis on the provision of feedback which will assist the student to be successful

in the treatment of patients requiring physical therapy services.

The Clinical Instructor should formally meet with the student at least one time per week to discuss the student’s strengths

and areas of performance which may require improvement. Assessments will be performed during the clinical rotations

PTA 206, PTA 280 and PTA 290. The assessment tools used by the program are weekly planning form and the Web CPI.

Web CPI will be utilized by the CI, Student, and ACCE. A training tutorial is required prior to clinical placement.

The key to successful clinical performance is ongoing and open communication between the Clinical Instructor and the

Student. Through the process of ongoing assessment, the student should be well aware of his/her level of performance at

the time formal assessments are made. There should be no surprises.

Exposure/Injury to the Student

The intent of the Mohave Community College PTA program is to promote the highest quality of care and safety for clients,

students, staff and faculty. The PTA program is following accepted policies, standards, and guidelines set for by Mohave

Community College, the Occupational Safety and Health Administration (OSHA).

Students are taught Universal Precautions in the first PTA course (PTA 200) and content is practiced and reinforced

throughout the program. Students are responsible for using universal precautions and for any personal expenses that may

occur in the event of an exposure. Students are encouraged to check their health insurance policy for coverage.

Holidays/Weekends

Students may be expected to report to their clinical assignment if their clinical assignment falls on the holiday and/or

weekend.

Hours/Days

While normal hours are 8 am to 5 pm, the individual clinical sites may modify these hours to suit their specific needs. The

student will be required to work the same hours as the clinical instructor which could vary. Students are expected to work

a minimum of 40 hours per week.

Pregnancy

Students who become pregnant may be susceptible to delays in completing their clinical education experiences which could

also delay completion of the program. Each case will be evaluated individually to determine the safest plan for the mother,

child, program and clinical site. The Program Director and ACCE will make the final decision regarding student progression

with the PTA Program and placement in clinical education courses.

Tardiness

Students are expected to BEGIN work at their scheduled starting time. The student must contact the ACCE and their clinical

instructor (CI) if unable to report to the clinical site at the appointed starting time. All absences must be reported to the

ACCE and the CI as soon as possible.

Transportation

Each student is required to provide their own transportation to the clinical site. A valid driver’s license is required. Every

attempt is made to arrange the location of the clinical education site with respect to the geographic location of the student’s

residence. Understand that Mohave County is considered rural. If you have family in outlying areas (Arizona, Utah,

California, or Nevada) where you could stay during your clinical rotations, please inform the ACCE as soon as possible.

Students may be required to travel to and from the clinical site or find temporary housing during the clinical rotation. All

fees associated with housing and transportation to and from the clinical site is the responsibility of the student.

Informed Consent

Students in the Practice Setting

Patients have rights and responsibilities. One of the patient’s rights is to know who is treating them and their scope of

practice. It is your responsibility to be clear to the patients who you are (name and that you are a student) and what you will

be doing to them. Your clinical instructor can facilitate this exchange of information as well.

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Examples: CI exchange with patient: “Hi Mr. J. Today I have a student working with me. His/her name is Pat. Pat is going

to school to become a physical therapist assistant. Do you mind if Pat works with you today under my direct supervision?”

Sometimes, especially at the end of your clinical rotation, you may be approaching patients yourself. You still need to

inform them who you are and what you will be doing. For example, “Hi, my name is Pat. I am a student at Mohave

Community College in the physical therapist assistant program. I am working under the direct supervision of John Smith.

Do you mind if I work with you today?”

Remember that patients have the right to refuse treatment. Patients have the right to know that their decision of not working

with a student will not impact their care. Billing usually remains the same if a student works with a patient. Please respect

the patient’s right to refuse treatment with dignity and a smile. Inform your clinical instructor of the patient’s choice.

Request to stay for observation or ask your clinical instructor what else you can do (i.e. review the chart for the next person,

prepare a home exercise program for someone, etc.).

Cancellation of Clinical Rotation

The availability of clinical sites is critical to the success of the physical therapist assistant program at Mohave Community

College. In the event an offered clinical site will not be used for a particular time frame, the college will make every effort

to give notice to the clinical site a minimum of six weeks in advance.

Clinical sites are requested to alert the academic coordinator of clinical education (ACCE) a minimum of six weeks prior

to the start of the clinical rotation if circumstances will cause the clinical site to withdraw the offer to accept a student for a

particular time frame. It is acknowledged that last minute changes are often necessary. Every effort should be made on the

part of the Program and the Clinical Facility to avoid these situations as much as possible.

Records Required for Clinical Rotations

1. Background Check

2. Level 1 Fingerprint Clearance Card

3. Healthcare Provider CPR Card

4. Student Health and Immunizations

5. Health Insurance

6. Drug Screening

7. Required Current Vaccinations

8. Records required for clinical rotations (items 1-6)

need to be completed by the end of the first semester

unless granted special permission by the ACCE.

PreCheck Background Check/Level 1 Fingerprint Clearance Card

Clinics require students to have a background check and fingerprinting completed prior to participating in their clinical

education experience. All students will be required to complete these tasks.

Any questions about prior convictions have to be discussed with the director. A positive result on the background check

may preclude the student from clinical affiliations at certain facilities since each clinical site has their own criteria. This

will impact progression through the PTA program. The student will be required to follow readmission policy, or apply for

entry as a new student. In addition, a positive background check will need to be addressed with the state board of physical

therapy. The positive background check may preclude the student from obtaining licensure in the state he or she chooses

to work in.

Students with a positive background check will be notified by the Program Director of the potential impact on the

progression through the PTA Program. It is the student’s responsibility to notify the Program Director of any changes

in their background due to criminal activity.

Students are required to notify the director within 7 days of any offense. Failure of notification will impact progression

through the PTA program. The program has the right to require another background check at any time at the student’s

expense.

a. PreCheck Background Check: Obtain a PreCheck Background Check at www.mystudentcheck.com.

After PreCheck Background Check has been cleared, select school-Mohave Community College District,

and then PTA from the drop-down menu.

b. Level 1 Fingerprint Clearance Card Application: Complete the Level 1 Fingerprint Clearance Card

application directly from DPS at https://fieldprintarizona.com/

. For frequently asked questions please

visit: http://www.azdps.gov/services/fingerprint/. A Level 1 Fingerprint Clearance Card is valid for six

years and must remain valid throughout the PTA program.

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Physical Therapist Assistant Program

Healthcare Provider CPR

All students must have a valid Healthcare Provider (or equivalent) CPR card that is valid for all clinical rotations. CPR

training must be obtained through either the American Red Cross or the American Heart Association, classes offered through

Community Outreach program at MCC. CPR is good for 2 years.

Student Health and Immunizations

Students must obtain a physical exam and submit it to the PTA program office by the end of the first semester. Students

are required to maintain immunizations. This includes yearly 2-step TB testing, the Hepatitis B vaccine series, tetanus

(every 10 years), and other routine childhood immunizations.

Some facilities require further immunizations, updated physical exams and health insurance which students will have to

provide prior to being accepted for a practicum in that facility. Students should be aware that there is a potential risk of

exposure to Hepatitis B and other communicable disease during clinical affiliations. Students will be oriented to safety

procedures at Mohave Community College and at all clinical facilities. Students will have access to faculty within their

clinical area for any additional information. Students are expected to accept all types of patient assignments. Students are

financially responsible for their personal health care/hospitalization costs incurred while participating in the PTA program.

Health Insurance

Students will be required to provide proof of health insurance by the end of the first semester. The program will provide

information to clinical sites on request. Health insurance is not provided by the college to cover injury during the course of

academic and clinical training. If you do not have health insurance, contact a local insurance provider. Failure to obtain

health insurance will impact progression through the PTA program

Drug Screening

A drug screening test is required of all students for clinical assignments. In case of a positive result, the results will be sent

to a medical review officer who will investigate with the student the reason for the positive test result. The medical review

officer will contact the program and indicate if the test result was valid or a false positive. The student’s ability to participate

in the clinical education rotation will be dependent on the medical review officer’s report. A positive report will be grounds

for disciplinary action, if not cleared by the medical review officer. Action will impact progression through the PTA

program. Some clinical sites may also require screening for nicotine. Students who test positive for nicotine may not be

able to be placed at some clinical sites but are not excluded from the program.

Injury and Emergency Procedures

Procedures for Handling an Injury during Clinical Assignment - Evaluate the injury immediately.

Medical Emergency:

1. If someone needs immediate medical attention, call 911 –even if they protest or later refuse medical services.

2. Provide first aid or the extent of your ability and training.

3. Keep the injured or ill person as comfortable as possible; do not move (unless remaining would cause further injury

or risks).

4. Notify Supervisor or Campus Dean.

The Mohave Community College liability insurance policy does not cover a student’s injuries or emergencies. Payment of

all healthcare charges not covered by personal health insurance is the responsibility of the student.

Mohave Community College incident reports will be filed in the student’s folder. In the event of injury and at the discretion

of the clinical instructor and the program director, the student will be given up to a week off from the clinical training. Days

of absence must be made up by extending the clinical experience. The student may be required to submit a physician’s

prescription to refrain from participation in the clinical experience and/or a release to re-enter the clinical education facility.

Clinical Practice Settings

Practice settings may include all of the following: acute care hospital, rehab hospital (includes rehab unit located within an

acute care hospital), extended care facility, outpatient care (includes free-standing practices as well as outpatient rotations

in a hospital based program). Other practice settings may be available at the discretion of the Program Director. During the

3 clinical rotations, every attempt will be made to have the student exposed to a minimum of two distinct physical therapy

practice settings.

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NOTE: To be considered as an active clinical site for the program the site must meet the following conditions:

 The facility has a completed clinical agreement with Mohave Community College which outlines the specific

responsibilities of the facility and the college with regard to clinical education of physical therapist assistant

students.

 It is recommended that the assigned Clinical Instructor has a minimum of one year of experience in the practice

setting for the specific clinical rotation. Clinical Instructors may be physical therapists or physical therapist

assistants.

 The facility is able to provide an adequate clinical case load for the specific clinical rotation to allow for the

evaluation of the student’s performance in the specific practice setting.

Clinical Competencies

The MCC PTA program includes three full-time clinical experiences in the curriculum.

Student competence prior to clinical assignment

The following academic standards, lab and skill competencies will be performed before students are approved to participate

in PTA 206 (Clinical Practicum I), PTA 280 (Clinical Practicum II) and PTA 290 (Clinical Practicum III).

The first clinical affiliation (PTA 206) is scheduled for the summer between the first and second year (but may be subject

to change). Skill competency (80%) with 100% on critical safety elements must be demonstrated prior to student affiliation

with clinical site.

First Clinical Rotation

PTA 206 is the first of the clinical education experiences and allows students to practice basic skills in the clinical

environment which have been learned during the first year in the program. These skills include basic patient assessment

techniques, gait and transfer training, wheelchair mobility, heat and cold modalities, traction, massage, intermittent venous

compression, therapeutic light applications, and therapeutic exercise and Electromodalities.

Competency

Critical Safety Elements

• Transfer training

• Gait training with assistive devices and stairs

o Foot wear, application of gait belt, locked wheelchair, maintain

documented precautions including WB status, proper guarding

o Proper footwear, application of gait belt, maintains documented

precautions including WB status, proper guarding.

• Therapeutic Exercise

• AROM and Prom Stretching

o Proper instruction, body mechanics, and maintenance of

documented precautions.

• Vital signs

o Right cuff size, opening pressure relief valve, rapid evacuations of

cuff following determination of diastolic blood pressure

• Basic Manual Muscle Testing and Goniometry

o Utilization of proper body mechanics, maintains documented

precautions and appropriate patient positioning.

• Universal Precautions

o Proper sequencing for donning and doffing

• Superficial Heat (includes hot packs, paraffin,

hydrotherapy, fluidotherapy)

o Reassessment of skin following intervention, call system available

if PT is unsupervised for periods of time, knowledge of absolute

contraindications

• Superficial Heat

• Includes Hot Packs,

• Paraffin

• Hydrotherapy

• Fluidotherapy

o Reassessment of skin following intervention, call system available

if patient is unsupervised for periods of time, knowledge of

absolute contraindications and precautions (critical for all

superficial heat modalities)

o Positioning of body part remains constant to avoid burns

o All Temperature check and appropriate for treatment outcomes

o Ensure system is closed before turning machine on.

• Deep Heat

• Includes Ultrasound

• Electromagnetic Radiation (Shortwave

Diathermy)

o Knowledge of absolute contraindications and precautions, skin

reassessment following intervention, proper care of wand/crystal,

100% contact skin during application, continuous movement

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o Knowledge of absolute contraindications and precautions,

removal of jewelry, skin reassessment following intervention,

appropriate moisture control measures performed

• Traction

• Includes cervical, pelvic and over the door

o Knowledge of absolute contraindications and precautions, correct

application of harnesses, check poundage

• Intermittent Venous Compression

o Knowledge of absolute contraindications and precautions, cover

any open wounds with absorbent material, check poundage

• Light Therapy and Laser Therapy

o Knowledge of absolute contraindications and precautions, proper

wand care, proper application of wand (no movement), 100%

contact to skin, safety glasses

• Massage and Soft Tissue Mobilization

o Knowledge of absolute contraindications and precautions

• Electrical Stimulation

• Includes TENS, low and high volt

currents, microcurrent, NMES, functional

e-stim and biofeedback

o Knowledge of absolute contraindications and precautions, proper

electrode placement including contact, skin reassessment, check

for latex allergies, check skin sensation prior to application

• Cryotherapy

• Includes cold packs, ice massage

o Knowledge of absolute contraindications and precautions, skin

reassessment

• Iontophoresis

• Phonophoresis

o Knowledge of absolute contraindications and precautions, proper

electrode placement including contact, skin reassessment, check for

latex allergies, check skin sensation prior to application

Students Entering PTA 206, Clinical Practicum I, Have Completed the Following Courses:

 Introduction to Physical Therapy (PTA 101)

 Kinesiology (PTA 103)

 Patient Mobility Techniques (PTA 200)

 Physical Therapy Modalities (PTA 202)

 Pathology (PTA 203)

 Communication in Physical Therapy (PTA 205)

 Electromodalities (PTA 214)

 Wound Care (PTA 215)

Students Have Demonstrated Competency and Entry Level Skills for The Physical Therapist Assistant In The

Following Areas:

 Transfer training

 Gait training with assistive devices

 Active and passive range of motion

 Progressive resistance exercise

 Therapeutic exercise with equipment

 Vital signs

 Stretching

 Posture and body mechanics

 Goniometry

 Basic manual muscle testing

 Theory and application of superficial heat – hot packs, paraffin, hydrotherapy, fluidotherapy

 Theory and application of deep heat – ultrasound and shortwave diathermy

 Cervical and pelvic traction

 Intermittent venous compression

 Light and Laser Therapy

 Massage and soft tissue mobilization

 Universal precautions

 Patient positioning

 Theory and application of electrical stimulation – includes TENS, low and high volt currents, microcurrent,

electrical muscle stimulation, and functional electrical stimulation, Iontophoresis and phonophoresis.

 Biofeedback

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Lecture exams skill competencies and lab practical’s will be given frequently to assure that student comprehension and skill

performance levels are being achieved. Safety precautions are stressed throughout lecture and lab activities.

Second and Third Clinical Rotations

In PTA 280 and 290, students will continue to apply the skills mastered in PTA 206. In addition, several new skills will be

assessed including treatment techniques for patients with cardiopulmonary dysfunction, brain injury, spinal cord injury,

amputations, developmental delay, and specific orthopedic conditions. The student’s ability to use orthotic/prosthetic

devices will also be assessed.

Students entering PTA 280 and 290, Clinical Practicum II and III will have completed the following additional courses:

 Rehabilitation of Special Populations (PTA 208)

 Orthopedics (PTA 210)

 Clinical Neurology (PTA 217)

Competency

Critical Safety Elements

• Orthopedic management of bone & joint

pathologies

• Basic orthopedic joint assessment

• Manual traction techniques for spine

• Grade I, II mobilization techniques for

extremity joints and spine

• Therapeutic Exercise

o Knowledge of common bone & joint pathologies

o Implement orthopedic management of pathologies

o Knowledge of absolute contraindications and precautions for manual

techniques

o Knowledge of assessment of willingness to move, end feel, mobility

and basic special tests to each extremity joint

o Knowledge and demonstration with positioning and implementation

of basic joint mobilization techniques

o Identify precautions and contraindications with joint mobilization

techniques

o Knowledge of selection, progression and delivery of therapeutic

exercise instruction

• Neuroanatomy: central and peripheral

nervous system

• Sensory and motor innervations

• Neurological Impairments: functional

movement problems

• Motor control & motor learning across the

lifespan

o Identifying central versus peripheral nervous system impairments

o Screening for sensory and motor deficits

o Identifying neurological deficits: progressive & Non-progressive

disorders

o Implementing appropriate positioning & interventions

o Identifying level of spinal cord injury

o Knowledge of the motor learning strategies

• Cardiopulmonary disorders

• Pediatric disorders

• Vestibular disorders

o Identifying cardiopulmonary deficits & use of assessment tools

o Implementing appropriate interventions for cardiopulmonary

disorders

o Knowledge of common pediatric disorders

o Implementing age appropriate interventions

o Knowledge of appropriate positioning for treatment

o Identifying common vestibular disorders

o Knowledge of appropriate positioning and treatment strategies

• Neuromuscular rehabilitation

• Orthotics & prosthetics

• Prescriptive wheelchair

o Knowledge of treatment strategies: PNF, NDT, constraint induced

therapy, coordination and balance retraining, motion sensitivity

training, vestibular rehab techniques

o Knowledge of use of orthotics & prosthetics, and the PTAs role

o Knowledge of maintenance with orthotics & prosthetics

o Knowledge of precautions & contraindications with orthotics &

prosthetics

o Knowledge of prescriptive wheelchair management, positioning &

seating

o Knowledge of the postural support components

o Demonstrate required measurements for wheelchair fitting

o Educate patients on wheelchair mobility

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Physical Therapist Assistant Program

 Physical Therapy Seminar (PTA 230)

Students will have demonstrated competency and ENTRY LEVEL SKILLS FOR THE PHYSICAL THERAPIST

ASSISTANT in the following additional areas:

 Proprioceptive neuromuscular facilitation

 Neurodevelopment treatment

 Orthopedic manual and exercise treatment

 Facilitation and inhibition techniques

 Pre-prosthetic and prosthetic training of the lower extremity amputee

 Use of orthotics

 Therapeutic exercises

 Chest physical therapy

NOTE: The clinical faculty may teach treatment techniques that have not been covered in lecture/lab but is responsible for

any consequences resulting from a student applying a technique which has not been covered in the academic setting.

Observational opportunities are invited and acceptable.

Program faculty come from clinical practice prior to teaching and have the greatest respect for our clinical sites and do not

feel that any student should be on a clinical affiliation without basic safety and competency skills.

Standards of approval for students to participate in the clinical education experience include:

1. All skill competencies must be passed.

2. All skill competencies safety requirements must be met.

3. All classes must be completed successfully prior to clinical education experience.

Students must achieve a minimal competency level of 80% for all PTA courses in order to progress forward in the program

and be in-line to graduate.

HIPAA

Health Insurance Portability and Accountability Act (1996)

HIPAA will be discussed more in length throughout your physical therapist assistant program. Here is a brief description

of what HIPAA involves.

HIPAA, which stands for the American Health Insurance Portability and Accountability Act of 1996, is a set of rules to be

followed by doctors, hospitals and other health care providers. HIPAA took effect on April 14, 2006. HIPAA helps ensure

that all medical records, medical billing, and patient accounts meet certain consistent standards with regard to

documentation, handling and privacy. HIPAA compliance can be summarized by the three major rules or standards:

1. HIPAA Privacy Rule

The HIPAA Privacy Rule mandates the protection and privacy of all health information. This rule specifically

defines the authorized uses and disclosures of "individually-identifiable" health information.

2. HIPAA Transactions and Code Set Rule

The HIPAA Transaction and Code Set Standard addresses the use of predefined transaction standards and code

sets for communications and transactions in the health-care industry.

3. HIPAA Security Rule

The HIPAA Security Rule mandates the security of electronic medical records (EMR). Unlike the Privacy Rule,

which provides broader protection for all formats of health information, such as print or electronic information,

the Security Rule addresses the technical aspects of protecting electronic health information. More specifically,

the HIPAA Security standards address these aspects of security:

a. Administrative security - assignment of security responsibility to an individual.

b. Physical security - required to protect electronic systems, equipment and data.

c. Technical security - authentication & encryption used to control access to data.

Student Clinical Education Requirements for Communication and Documentation

1. Students will fill out the weekly planning form. This will allow the student to communicate adequately with the clinical

instructor each week, review the past week and plan for the next week. The weekly planning form will be turned into

the ACCE at the completion of each week.

2. The PTA Web CPI will be completed by the student and the CI. The PTA Web CPI will be reviewed by the ACCE

after submissions.

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3. At the end of the clinical rotation, students will complete student evaluation of clinical site and CI. This document

will be turned into the ACCE at the completion of the clinical rotation.

4. The student will receive a grade for the clinical rotation following completion of the required documents.

Clinical Instructor Guidelines for Clinical Education for Communication and Documentation

1. The PTA program will submit clinical course goals and competencies to the Clinical Instructor and student.

2. CI will provide feedback on student performance as needed.

3. Students and clinical instructors will complete a written summary on weekly performance. This will be a short check

list from that will have a place to comment on strengths and weaknesses.

4. The student and clinical instructor will compare notes and discuss goals for the next week and goals for the overall

clinical course.

5. Any question of student performance and/or reaching clinical goals and competencies will be reported at the earliest

opportunity by the clinical instructor or the student.

6. Web CPI will be completed online.

7. The second half of the clinical will follow the same guidelines as the first half.

8. At the completion of the clinical rotation, the clinical instructor will submit their CPI through the CPI web to turn into

the ACCE for review.

Clinical Faculty Qualifications & Development

☆ All clinical sites will be given the APTA Guidelines and Self Assessments for Clinical Education booklet to help

determine faculty development needs from an individual and site-specific perspective. Filling out the form is voluntary.

☆ Clinical faculty needs will be assessed through student CI evaluations, self-assessment, ACCE communication, Clinical

Faculty Assessment form and clinical site visits.

☆ Clinical sites will be contacted regarding faculty development opportunities to improve their effectiveness as a clinical

site for MCC; these might be site-specific or global developmental opportunities.

☆ All clinical sites and instructors will be notified of educational offerings available to them in order to improve their

effectiveness as clinical instructors.

☆ Clinical faculty may have access to MCC library resources upon request.

☆ Social networking opportunities will be advertised through word of mouth, email, and the list-serve, depending on the

circumstance.

☆ The clinical faculty contact information is maintained by the ACCE and/or the program secretary.

☆ All clinical faculty need to have a minimum of 1 year of clinical experience.

Getting Started with the APTA Learning Center and CPI Web

ACCE/DCE/Program Staff, CCCE, CI, and Students will need to complete the APTA PTA Training in order to login to

CPI Web to complete student assessments. Visit the PTA CPI Web Clinical Assessment Suite Help Center to get started.

PTA CPI Web Clinical Assessment Suite Help Center:

 APTA PTA Training

 Logging in to PTA CPI Web

 Updating Information

 Editing the CPI

 Signing off on the CPI

*NOTE: American Physical Therapy Association (APTA) Guidelines for Clinical Instructors and Standards of Ethical

Conduct for The Physical Therapist Assistant can be found on www.apta.org.

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Physical Therapist Assistant Program

Appendices

Mohave Community College * 1977 Acoma Blvd, West * Lake Havasu City, AZ 86403 * PTA Program Support 928-505-3351

Physical Therapist Assistant Program

Counseling Offense Form

This form will serve as documentation that the student has been notified of the issue(s) that the student is being

counseled on. This form will also document the period of time permitted to correct or improve the situation.

Student will abide by all student policies, particularly regarding attendance, maintaining a passing average and

following up on conferences with program staff. The student will understand that he/she is expected to pass all

exams during the probationary period and thereafter. Failure to comply with the terms will impact progression

through the PTA program.

Student Name: ___________________________________________Date: ___________________________

Type of Offense Being Counseled For:

Type of Documentation:

Class Lab Clinical

Advisement:

Verbal Written Warning Probation Course failure

1. Has the student been previously warned? Yes No

2. If yes, when? _____________________________________________________________________

3. Was the offense involving the same situation? Yes No

4. Has the student reached the maximum number of offenses? Yes No

5. Time given to correct this situation: ____________________________________________________

I, __________________________________, have read and understand the incident report filed on me for the

offense(s) I have committed. I will exercise my right to appeal procedures if it is necessary.

___________________________________________

Print Student Name

___________________________________________ Date: ___________________________________

Student Signature

___________________________________________ Date: ___________________________________

Witness Signature

Mohave Community College * 1977 Acoma Blvd, West * Lake Havasu City, AZ 86403 * PTA Program Support 928-505-3351

Physical Therapist Assistant Program

Program Complaint Form

The PTA program complaint form will be used for handling complaints that are related to the PTA program from

external sources. This form will be kept as a record of any complaint about the program; including the nature of

the complaint and the disposition of the complaint.

Person(S) Filing Complaint: _______________________________________________

Contact Made By: Phone Fax Email Visit

Nature of Problem:

__________________________________________________ ___________________________________

Signature Person(S) Filing Complaint Date

For Office Use Only:

Fact Finding:

Data to Verify Complaint:

Suggested Steps for Resolution:

Info Provided To: ______________________________________ on (Date) ___________________________

Contact Made By: Phone Fax Email Visit

Results (Include Date of Resolution):

Print Name: __________________________________ Campus Dean: _____________________________

Signature: ____________________________________ Signature: _________________________________

Person(S) Completing Form

Date: __________________________________ Date: _____________________________________

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