Fillable PTA Clinical Affiliation Site Request Form (Indian Hills Community College)

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PTA Clinical Affiliation Site Request Form (Indian Hills Community College)

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Clinical Aliation Site
Request Form
Physical Therapist Assistant Program
Requests by students will be considered when scheduling clinical Assignments.
Actual placement will be based upon availability.
Name:
“Home Base “during Clinical:
Clinical I - 10 Fridays (or Wednesdays)
Dec 4, 11, 18, 2020, Jan 8, 15, 22, 29, Feb 5, 12, 19, 2021
First Choice
Second Choice
Third Choice
Comments:
Clinical II - weekly for ten weeks
June 4, 11, 18, 25, July 9, 16, 23, 30,
August 6, 13, 2021
Clinical III - Monday through Friday for four weeks
Oct. 25-Nov. 19, 2021
Clinical IVA - Monday through Friday for five weeks
Feb 28-April 1, 2022
Spring Break
April 4-8, 2022
Clinical IVB - Monday through Friday for five weeks
April 11-May 13, 2022
Students will complete Site Request Forms for the
remaining clinicals at a time designated by the ACCE
when the date for the aliation nears.
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PTA Clinical Affiliation Site Request Form (Indian Hills Community College)

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Completed 18 July 2020

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