Ptcas Form – Fill Out and Use

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