ELGIN COMMUNITY COLLEGE PTA
2020 admittance (revised April 2019) Page 1 of 1
https://elgin.edu/academics/departments/physical-therapist-assistant/program-
admissions/EMPLOYMENT VERIFICATION AND QUESTIONS
Name of Applicant: ____ _____________________ __ ECC Student ID # __________________
Purpose/Instructions:
• To ensure PTA program applicants are aware of basic aspects of physical therapy regarding the environment, basic patient
care, physical and cognitive demands. Employment must occur in the state of Illinois in one of the following physical
therapy environments: acute care, skilled nursing facility, in-patient or out- patient rehabilitation, out-patient orthopedic,
home care, pediatric or pediatric educational settings.
• Work experience must occur within 2 years of application Feb 15
th
submission date and occur in the state of Illinois.
• Employment of 3 months or more as a Physical Therapy Aide or Technician in a physical therapy setting in Illinois.
• Supervision provided by an Illinois licensed physical therapist.
• Applicant to respond to the 3 questions on the bottom of this form. See below for further instructions/clarification.
• Attach this form and responses to questions to the PTA Student Application Information form—submit to Health
Professions office A 106. (applicants encouraged to make copies for own files)
Complete all the following information:
Type of employment experience (hospital, outpatient, nursing home, etc). ______________________________________
Position title of applicant during employment: _____________________________________________________________
Dates (inclusive) of the employment experience:
months or
___________________________________________________________
This applicant has completed _________ _______years (select one) of employment in the Illinois physical therapy
department at:
Printed Name of facility: ________________________________________________________
Facility Address: ______________________________________________________________
_____________________________________________________________
Supervising Illinois Licensed Physical Therapist or Licensed Physical Therapist Assistant to complete:
I verify that the above information accurately represents the applicant’s employment experience with me at this facility.
Printed name of Illinois licensed PT/PTA: ______________________________________ _______ (circle one) PT PTA
Signature of supervising PT/PTA: ____________________________________________ Illinois License # ______________________
Phone contact information: _________________________________ (phone or email) Date: ____________________
The applicant demonstrated professional behaviors during employment including, timeliness, respect, appearance, curiosity,
interest and attentiveness and I would rehire this person. (circle one) Yes No
Office stamp or business card must be included here:
________________________________________________________________________________________ _____
Applicant Questions and Instructions: Limit each essay to approximately 1 typed page per question--font of 12 and double spaced
(max of 500 words). Attach your essays to this form and the PTA Student Applicant Information Form (blue)--submit to the Health
Professions office, A 106. Suggest a copy of all items being submitted maintained for your personal files.
1. What is Physical Therapy? Who are Physical Therapy providers?
2. Describe a life experience that required problem solving. What was the problem and how did you solve it?
3. What characteristics or experiences do you have that will help you effectively communicate with the patients? What do you
believe may limit your ability to effectively work with patients?
Office stamp or business card
must be included where
indicated below
