Physical Therapy Observation Hours
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Facility Name:
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Street Address:
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City:
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State:
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Zip Code:
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Experience Type:
____Paid ____ Volunteer ____Both
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PT Settings & Hours of Experience
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Inpatient Settings (generally admits patients overnight)Hours Completed
Hours Planned / In Progress
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____Acute Care Hospital
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____Nursing Home / Skilled Nursing Facility / Extended Care Facility
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____Rehab / Sub Acute Rehab
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____Other Inpatient Facility
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Outpatient Settings (no overnight patients)Hours Completed
Hours Planned / In Progress
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____Free-Standing PT or Hospital Clinic
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____Home Health
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____Industrial / Occupational Health
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____School / Pre-school
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____Wellness / Prevention / Fitness
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____Other Outpatient Facility
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Total # of Hours:00
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Patients Observed (check all that apply)
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____General Orthopedic (musculoskeletal) ____Neurological (neuromuscular) ____Geriatrics ____Sports ____Women's Health
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____Integumentary (wound management) ____Cardiovascular / Pulmonary ____Pediatrics ____Aquatics ____Other
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Dates & Hours Observed
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Date# of HoursPT ObservedWhat did you learn?
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Total Hours:0
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