Fillable Observation Hours Facility Enter your paid or volunteer (City of Oakland)

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Observation Hours Facility Enter your paid or volunteer (City of Oakland)

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File type: PDF

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Observation Hours
Enter your paid or volunteer observation hours in this section. You will need
to use a separate copy of this form for each facility and/or experience. Please
include all forms in one file. Please reach out to your Admissions Counselor
should you have any questions.
Facility
Facility Name:
Street Address:
Street Address 2:
City:
Country:
State/Province:
Postal Code:
Experience Dates
Start Date:
End Date:
Experience Details
Recognition Type
Paid Volunteer Both
Setting and Hours of Experience: Check and enter hours for all settings that apply to your
experience in this facility.
INPATIENT settings: Facility generally
admits patients overnight
Hours Completed
Hours Planned/
In Process
Acute Care Hospital
Nursing Home/Skilled Nursing
Facility/Extended Care Facility
Other Inpatient Facility
Rehabilitation/Sub-acute Rehabilitation
OUTPATIENT Settings: Facility has no
overnight patients
Hours Completed
Hours Planned/
In Process
Free-standing PT or Hospital Clinic
Home Health Industrial/Occupational Health
Other Outpatient Facility
School/Pre-school
Wellness/Prevention/Fitness
TOTAL # OF HOURS COMPLETED FOR
ALL SETTINGS
Patient Diagnoses / Patient Observed: (Check all that apply)
General Orthopedic (musculoskeletal)
Neurological (neuromuscular)
Cardiovascular / Pulmonary
Integumentary (wound management)
Geriatrics
Pediatrics
Sports
Aquatics
Women’s Health
Other
PT Observation Hours Verification
In order to get your PT Observation Hours Verified, you must save this document and email it to
your PT Supervisor for verification. Please fill out the below section on your PT Supervisor.
Physical Therapist Supervisor
Enter information about the physical therapist who supervised the PT observation hours you
entered on this form.
PT First Name
PT Last Name
PT Phone Optional
PT Email
PT License Number Optional
PT License State Optional
This section should only be filled out by the PT supervisor.
Physical Therapist Response
I approve the PT Observation Hours entered by this applicant.
If you cannot or do not approve of the PT Observation hours entered by this applicant, do not respond to this request.
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Observation Hours Facility Enter your paid or volunteer (City of Oakland)

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Completed 27 October 2021

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