EASTERN FLORIDA STATE COLLEGE
PHYSICAL THERAPIST ASSISTANT PROGRAM
CLINICAL SITE FORM
Name of Facility: Date:
Clinical Coordinator Clinical Education (CCCE) is the person at the facility who will be responsible for the
clinical education process of the student. Please write name and credentials.
Facility Address: (include city, state, and zip code)
Phone Number: Extension: Fax Number:
E-mail Address: Website:
All EFSC PTA students will have the following criteria completed prior to their clinical practicum:
- Proof of health clearance and required vaccinations (TDP, MMR, Hepatitis B, Varicella, Influenza, TB)
- Drug screen and background check
- First aid and CPR certified
- HIPAA and OSHA educated
- Personal health insurance
- Professional liability insurance
If your clinical facility has other specific requirements than those listed above, please specify below:
Which of the following best describes the ownership category for your clinical site?
Corporate/privately owned Government Agency Hospital
Physician owned PT/PTA owner Other
Which of the following best describes the type of facility you are:
Acute care/Inpatient Industrial/Occupational Health
School/Pre-School Program Ambulatory Care/Outpatient
Multiple-level Medical Center Wellness/Prevention Program
Nursing Home/SNF Private Practice
Home Health Care Federal/State/County Health
Sub-acute Rehabilitation
Which best describes your location site?
Rural Suburban Urban
