Ptcas Form PDF Details

The pursuit of a career in physical therapy demands rigorous preparation, part of which involves accumulating relevant experience in various settings. For individuals targeting admission into physical therapy programs, the Physical Therapy Centralized Application Service (PTCAS) form plays a pivotal role in this process. Specifically designed for those who need to have their physical therapy observation hours verified by a licensed physical therapist, the Physical Therapy Observation Hours Verification Form is a crucial document. It requires detailed input from applicants regarding their experiences across different settings, including both inpatient and outpatient facilities. The form not only captures the duration and nature of these experiences—categorizing them as paid, volunteer, or both—but also the types of patient diagnoses and populations observed. Critical instructions guide both the applicant and the verifying physical therapist on how to accurately complete and submit the form. Additionally, the document offers a section for the physical therapist to endorse the applicant's potential as a healthcare provider. This endorsement can significantly influence admissions decisions, making the accurate and thorough completion of this form essential for prospective physical therapy students. This process underscores the importance of comprehensive and verifiable hands-on experience in the highly competitive field of physical therapy.

QuestionAnswer
Form NamePtcas Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesobservation hours form, therapy observation form, paper form for physical therapy observation hours, ptcas observation hours verification form

Form Preview Example

Physical Therapy Observation Hours

VERIFICATION FORM: Extra

Form is only intended for use by individuals who need a PT signature for a future admissions cycle Some programs require a licensed PT to verify your physical therapy experiences. If required, provide this completed form to the appropriate PT for signature. Type or neatly handwrite your information directly onto this form, leaving your PTCAS ID number blank. Once you are ready to apply via PTCAS, enter all of your PT experiences on the PTCAS application exactly as they appear on this signed form. Select paper verification type. Print and attach the new (bar-coded) PTCAS verification form to this signed form. The PT does not need to sign the new form, if no changes. Send both forms in a single envelope to PTCAS. NOTE: If there are any changes to your PT experience after this form is signed, a PT must sign a new form to verify your revised hours.

Name of Applicant: _______________________________________________________ PTCAS ID#:_______________________

Name of Facility: ___________________________________________________________________________________________

Street Address for Facility: ___________________________________________________________________________________

City: ___________________________________________

State: ___ ___

Zip/ Postal Code: ________________________

Country: ___________________________________________

 

Name of Physical Therapist: ________________________________________________________________________________

PT License Number: ____________________________ State of PT License: ___ ___ PT Phone #:______________________

Instructions to physical therapist: You must enter your PT licensure information above.

PT Email: ____________________________________________________ PT Will Also Submit a Reference?

Yes

No

Type of Experience:

Paid

Volunteer

Both Start Date: ___________________

End Date: ____________________

PT Settings and Hours of Experience: Check and enter hours for all settings that apply to applica t’s experience in this facility.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INPATIENT Settings: Facility generally admits patients overnight

 

 

Hours Completed

 

 

Hours Planned / In-progress

 

 

 

Acute Care Hospital

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rehabilitation/Sub-acute Rehabilitation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Home/Skilled Nursing Facility/ Extended Care Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Inpatient Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OUTPATIENT Settings: Facility has no overnight patients

 

 

Hours Completed

 

 

Hours Planned / In-progress

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Free-standing PT or Hospital Clinic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School/Pre-school

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wellness/Prevention/Fitness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Industrial/Occupational Health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Outpatient Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL # OF HOURS COMPLETED FOR ALL SETTING

 

 

 

 

 

 

 

 

PT Patient Diagnoses/Populations Observed: Check all below that apply to the applica t’s experience at this facility. If the applicant did not directly observe a PT with a particular patient population, do not check box, regardless of whether the facility provides related services.

General Orthopedic (musculoskeletal)

Pediatrics

Neurologic (neuromuscular)

Sports

Cardiovascular / Pulmonary

Aquatics

Integumentary (wound management)

Wo e ’s Health

Geriatrics

Other

Taking into consideration these characteristics, how do you think this person would perform as a health care provider?

I highly recommend this applicant as a health care provider.

I recommend this applicant as a health care provider.

I recommend this applicant as a health care provider, but with some reservations.

I am not able to recommend this applicant as a health care provider.

I do not have sufficient information about the applicant to respond to this question.

Signature of Physical Therapist

Date

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completing therapy observation form step 1

Inside the field INPATIENT Settings Facility, IndustrialOccupational Health, TOTAL OF HOURS COMPLETED FOR ALL, PT Patient DiagnosesPopulations, General Orthopedic, Integumentary wound management, Pediatrics Sports Aquatics, Taking into consideration these, I highly recommend this applicant, and Signature of Physical Therapist provide the details the system requires you to do.

Completing therapy observation form step 2

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