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POLK STATE COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM OBSERVATION (Polk State College)

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POLK STATE COLLEGE
PHYSICAL THERAPIST ASSISTANT PROGRAM
OBSERVATION VERIFICATION FORM
Studentsmustshowverificationofaminimumof50hoursofphysicaltherapyobservationexposureinorderto
beconsideredforadmissiontotheprogram.Experienceinthreeormoredifferentclinicalsettingsisrequired.
Directions:Pleaseuseoneformforeachfacility.Alicen sedphysicaltherapistorphysic altherapist
assistantmust
signtheform.Duplicateadditionalformsasneeded.
Tobecompletedbythestudent
StudentName:StudentID#:
Address:_________ ___ ___ ___ _____________ ___ ___ ___ __ ___ ___ ___ __ ___ ___ ___ __ ___ ___ ___
NameofFacility:_________ ___ __ ___ ___ ___ __ ___ ___ ___ __ ______________ ___ ___ __ ___ ___
Address:_________ ___ ___ ___ _____________ ___ ___ ___ __ ___ ___ ___ __ ___ ___ ___ __ ___ ___ _
Phone:
Typeoffacility:AcuteCarehospital(pediatric/adult) HomeHealthCare
 SkilledNursing(SNF)/LongTermCare Othe r: ____________ ___ _
 OutpatientOrthopedics/Sports/G en eral /N eu rol ogic 
OutpatientPediatrics
SchoolBasedPediatr ics
Tobecompletedbythesupervisin gtherapist.
Totalnumberofhoursperformedbythestudent :_________
Wasthestud e n tconsistentlyontime? YES NO
Wasthestud e n tconsistentlydressedappropriately? YES NO
Didthestudentconsistentlyactprofessionally? YES NO
Didthestudentconsistentlybehaveethically? 
YES NO
Comments:___ ___ __ ___ ___ ___ __ ___ ___ ______________ __ ___ ___ ___ __ ___ ___ ___ __ ___ ___ ___ __ ___ ___ __
____________ ___ _____________ ___ ___ ___ __ ___ ___ ___ __ ___ ___ ___ __ ___ ___ ___ __ ______________ ___ ___
____________ ___ _____________ ___ ___ ___ __ ___ ___ ___ __ ___ ___ ___ __ ___ ___ ___ __ ______________ ___ ___
PT/PTASignature:License#:
PT/PTAName(Printed):Date:
OBSERVATION SUMMARY
Pleasesummarizewhatyoulearnedduringyourobservationexperienceatthisfacil ity.
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ObservationAttendanceLog:
Dates Times PT/PTAInitials
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____________ ___ _____________ ___ ____ ____________ ___ __ _
StudentSignatureDate
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POLK STATE COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM OBSERVATION (Polk State College)

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Completed 10 October 2020

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