Program Information Manual Physical Therapist Assistant Program

Transcription

Physical Therapist Assistant Program
Program Information
Manual
2014-15 Academic Year
Mohave Community College
Table of Contents
Equal Opportunity Policy Statement .................................................................................................................................................2
Accreditation Status ..................................................................................................................................................................................2
Frequently Asked Questions .................................................................................................................................................................4
Program Of Study .......................................................................................................................................................................................9
Program Requirements............................................................................................................................................................................9
Program Costs ........................................................................................................................................................................................... 11
Clinical Needs Check List...................................................................................................................................................................... 14
Physical Examination Form ................................................................................................................................................................ 15
Department Of Public Health Pricing ............................................................................................................................................. 17
Application Packet ................................................................................................................................................................................... 18
Application Checklist ............................................................................................................................................................................. 19
Admission Requirements And Selection Criteria: .................................................................................................................... 20
Application .................................................................................................................................................................................................. 21
Admission Application Disclaimer .................................................................................................................................................. 22
Drug Screening Disclaimer .................................................................................................................................................................. 23
Criminal Background Self-Disclosure ............................................................................................................................................ 23
Essential Functions Requirements .................................................................................................................................................. 25
Observation Hours .................................................................................................................................................................................. 27
Observation Hours Verification ........................................................................................................................................................ 29
Background Checks ................................................................................................................................................................................. 30
Fingerprint Cards ..................................................................................................................................................................................... 30
Student Demographic Information ................................................................................................................................................. 31
EQUAL OPPORTUNITY POLICY STATEMENT
Mohave Community College does not discriminate on the basis of sex, color, race, religious preference, age,
disability, national origin, Veteran status or any other legally protected class in any of its policies, practices,
and procedures, and it is an affirmative action and equal opportunity employer. For more information, call
the Human Resources Office at 928.757.0835, 1971 Jagerson Ave., Kingman, AZ 86409. Grievance
procedures are available at the Mohave Community College libraries in Bullhead City, Colorado City,
Kingman and Lake Havasu City.
ACCREDITATION STATUS
NOTICE TO STUDENTS
Physical Therapist Assistant Program at Mohave Community College is accredited by the Commission on
Accreditation in Physical Therapy Education (CAPTE), 1111 North Fairfax Street, Alexandria, Virginia 22314;
telephone: 703-706-3245; email: [email protected]; website: www.capteonline.org.
MOHAVE COMMUNITY COLLEGE * 1977 ACOMA BLVD. W. * LAKE HAVASU CITY, AZ 86404 * 928-505-3351 PROGRAM SUPPORT
MCC Form EDU 0032 (Revised 7/1/2014)
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Dear Prospective Student:
Thank you for your interest in the Physical Therapist Assistant Program at Mohave Community College.
Please review the application form prior to completion. Once you have made your decision to apply to the
program, complete all the required steps.
Due to limited amount of seats that are available in this program, and the amount of applications that we
receive, the applications into the program will only be accepted during the designated application period
of January 5, 2015 to April 24, 2015. Twenty (20) students will be selected for admission into the PTA
program. See the Admission Criteria and rating system located in this packet for more information.
Applications will be considered as students apply.
Please note that the curriculum and prerequisites for the program will be revised periodically. It is the
applicant’s responsibility to remain aware of changes that occur. For additional information, please access
one of the resources below:
1. Website: www.mohave.edu
PTA Information: http://www.mohave.edu/academics/certificates/pta
Phone: 1-866-664-2832
2. Liz Briere PT, DPT
Director of PTA program
Phone: (928)505-3347
E-mail: [email protected]
3. Tamra Coleman, PT, DPT, OCS, COMT
ACCE, Resident Faculty
Phone: 928-302-5323
4. Jennine Ramirez:
Program Secretary:
Phone: (928)505-3351
Best wishes in you educational and career pursuits.
Sincerely,
Liz Briere PT, DPT,
Director of Physical Therapist Assistant Program
Application Process: Prior to applying to the program, please complete the admissions application
process.
See link below:
https://jics.mohave.edu/ICS/Admissions_Apply_Online/Application_for_Admission.jnz
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FREQUENTLY ASKED QUESTIONS:
1. WHAT CAN I DO TO GET READY NOW?
 Review the Essential Functions of a PTA found on page 25 to make sure you can perform those
selected activities.
 Complete requirements to obtain your high school diploma or GED.
 HOBET exam is required and reviewed for consideration into the program.
 Contact Academic Advising to determine your need for any assessment tests in English and Math
(COMPASS test).
 If needed, enroll in Transitional Math and/or English to be eligible for college level courses.
NOTE: In order to apply to the PTA program, students must receive an appropriate score on
the COMPASS exam, or successful completion of TRE 089 and TRM 091 (Prerequisite).
 By the spring semester, taking the following general education courses prior to applying for the
PTA program will increase your points toward admission.
o BIO 100 Biology Concepts (Prerequisite)
o COM 121 Interpersonal Communications OR COM 151 Public Speaking
o BIO 201 Human Anatomy & Physiology I
o BIO 202 Human Anatomy & Physiology II
o ENG 101 English Composition I
o PSY 101 Introduction to Psychology
o CIS 110 Introduction to Computer Information Systems
Recommended but not required courses:
o HES 113 Medical Terminology
o MEA 100 Medical Law and Ethics
*Be aware that some courses may have additional pre-requisites associated with them.
 The following students must take STU 101 prior to applying to the PTA program:
o Cumulative High School or College GPA of less than 2.5 (4.0 scale); and/or
o If you have not taken at least 12 credits in the last 3 years.
 Become certified in CPR at the Healthcare Provider level.
2. WHAT IS THE DIFFERENCE BETWEEN A PHYSICAL THERAPIST AND A PHYSICAL THERAPIST
ASSISTANT?
a. Physical Therapists (PTs) evaluate patients, determine the plan of care, and perform skilled
treatments.
b. Physical Therapist Assistants (PTAs) are supervised by the Physical Therapist. They help
the Physical Therapist by performing selected treatment activities listed in the plan of care.
3. WHAT IS PHYSICAL THERAPY?
a. Physical Therapy (PT) is the art and science of providing care to patients recovering from
injury or disease which has resulted in a loss of function. Physical Therapy interventions,
such as therapeutic exercises, gait training, electrical stimulation, functional training are
utilized to restore function to the highest level. Patients may include infants, children, adults,
and the elderly.
4. WHAT EDUCATION IS NECESSARY FOR A PTA LICENSE?
a. Physical Therapist Assistants attend community or technical colleges that offer an
associate’s degree. The program takes two years to complete. You must graduate from an
accredited Commission on Accreditation in Physical Therapy Education program (CAPTE) in
order to sit for the National Physical Therapy Examination for PTAs. (See question # 11)
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5. WHERE DO PTA’S WORK?
a. PTA’s work in hospitals, rehabilitation centers, skilled nursing facilities, outpatient clinics
and sports medicine centers. Work hours are generally during the daytime, Monday through
Friday. Weekend work is generally available or required at hospitals and skilled nursing
facilities.
6. HOW MUCH MONEY DO THEY MAKE?
a. The new graduate PTA can expect to earn $31,070 - $68,820 per year for a full time
position.
7. WHAT IS THE CURRENT JOB MARKET?
a. The job market for PTA’s is projected to continue to grow for the next several years both
locally in Arizona and throughout the country. The United States of Labor Statistics forecasts
that through 2020 the demand for Physical Therapist Assistants will grow by 45%, much
faster than the average for all occupations. Opportunities for individuals interested in
becoming Physical Therapist Assistants are expected to be very good.
8. WHY SHOULD I CONSIDER A CAREER IN PHYSICAL THERAPY?
a. A career in Physical Therapy is very rewarding. Each day Physical Therapist Assistants work
closely with their patients to help them recover from injuries or illnesses that have
temporarily or permanently changed their lives. PTA’s are important members of the
rehabilitation team. Helping people to progress back towards optimal health is a wonderful
experience.
b. PTA’s are men and women who enjoy challenging work, communicating with people, and
working in a team environment to assist patients to achieve their fullest rehabilitation
potential.
9. CAN I APPLY IF I HAVE A CRIMINAL RECORD?
a. Yes, you may apply to the PTA program if you have a criminal record. You must be able to
achieve clearance through a background check upon admission. You will also be required
to obtain a fingerprint clearance card prior to clinical education experience.
b. Upon graduation from the PTA program you must apply to the Arizona State Board of
Physical Therapy (ASBPT) for PTA certification. The ASBPT has the ultimate authority to
grant PTA certification in the state of Arizona. They can make this determination after
reviewing the PTA certification application, including examination of criminal history.
c. Agreements with the healthcare facilities require that students receive a Fingerprint
Clearance Card issued by the Arizona department of Public Safety. Additionally, a student
must not be listed on the Federal Government’s Office of the Inspector General’s Exclusion
List. Students that are unable to obtain either of these clearances will be prohibited from
attending the Physical Therapists Assistant Program at Mohave Community College.
10. DO I NEED TO PASS AN EXAMINATION TO BE A PTA?
a. To hold the title of Physical Therapist Assistant in Arizona, an individual must pass the
National Physical Therapy Examination (NPTE) for the respective level of education and
training. The examination is administered by the Federation of State Boards of Physical
Therapy (FSBPT).
Costs associated with applying for certification and taking the examination are
approximately $500.
11. HOW MANY STUDENTS WILL BE ADMITTED TO THE PROGRAM?
a. A new class of up to 20 students will be admitted each August to the traditional day program.
The number of students admitted may change depending on employment market conditions
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and the availability of clinical training sites. There is a selection process and a deadline to
submit applications. In the event of a tie in rank, the space will go to the person who submits
their application the earliest.
12. WHAT HAPPENS TO MY APPLICATION IF I AM NOT ONE OF THE FIRST 20 APPLICANTS?
a. The application remains on file. If a student in the initial acceptance group is unable to take
their space, the position is offered to the next ranked applicant. For reconsideration for the
following year, a new application must be submitted.
13. HOW LONG DOES IT TAKE TO COMPLETE THE PROGRAM?
a. The program at MCC is an integrated 2 year program and can be completed in 5 semesters.
(Fall, Spring, Summer, Fall, Spring).
b. The program at Mohave Community College is an integrated 2 year program and can be
completed in 5 semesters. If all lecture laboratory, and clinical courses are completed
satisfactorily students will be able to graduate within 2 years. Many students take a year
prior to actually beginning the program courses to complete program prerequisites and
general education courses that are required for the Associate in Applied Science (AAS)
degree.
c. Please be aware that a semester below 12 credits can affect a student’s financial aid.
14. IS THIS PROGRAM ACCREDITED?
Physical Therapist Assistant Program at Mohave Community College is accredited by the
Commission on Accreditation in Physical Therapy Education (CAPTE), 1111 North Fairfax
Street, Alexandria, Virginia 22314; telephone: 703-706-3245; email:
[email protected]; website: www.capteonline.org.
15. WHEN ARE CLASSES SCHEDULED?
a. Lecture and lab courses may be scheduled Monday through Friday. Classes may begin as
early as 8:00 am and end as late as 5:00 pm. Depending on the semester, students may be in
class for 6-8 hours, 3-5 days per week. All of these classes are held on site at Mohave
Community College, Lake Havasu Campus.
b. Clinical education classes (PTA 206, PTA 280, and PTA 290) are Monday through Friday for
8 hours each day for 4-6 consecutive weeks. Extended hours and weekends are occasionally
necessary during clinical experiences. These classes require attendance at clinical facilities
that include hospitals, extended care facilities, and outpatient practices. There will be 3
clinical education courses.
c. Due to the rural nature of our location and the limited clinical site availability in Mohave
County, you will have to do at least one of your clinical education rotations outside of Mohave
County. If you have friends or family in the outlying areas, who would allow you to bunk
there for the defined weeks, the program will make the greatest attempt to place you in close
proximity to that location. The program reserves the right to place a student in a facility that
will best meet the student’s needs to fulfill the requirements of clinical education to become
a competent Physical Therapist Assistant.
16. CAN I WORK AND GO TO SCHOOL?
a. PTA program applicants are cautioned the PTA program is a rigorous course of study. The
program faculty recommends that work hours be kept to a minimum but each student must
make an individual decision about the number of work hours that he/she can handle while
continuing to make acceptable academic progress in the program. The program
recommends working no more than 20 hrs. Per week while enrolled in the PTA Program.
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The Clinical Education experience requires the student to be in the facility for a 40 hour work
week.
17. WHAT IS THE COST OF THE PROGRAM?
a. Students will pay the normal tuition plus a Program Fee of $1850 per semester. The program
fee will include student uniforms, student lab materials and tools, initial drug testing fees
and evaluation materials for clinical performance. Out of pocket costs include, but are not
limited to CPR, vaccines, medical clearance, costs for transportation & housing for clinical
rotations, health insurance, and additional tests required by individual facilities.
18. IS FINANCIAL AID AVAILABLE?
a. Financial assistance is available to eligible students in the form of grants, scholarships,
employment, or loans. Students may receive aid from one funding source or aid that may
be in a package from offered multiple sources. Students may contact the financial aid office
at (866)-664-2832 or visit the website at www.mohave.edu for additional information.
19. ARE THERE ANY SPECIAL SITUATIONS I NEED TO BE AWARE OF BEFORE I APPLY?
a. Students are required to complete three clinical education courses during the program. This
is a series of work experiences with patients in a variety of off-campus settings, under the
supervision of practicing PTA’s and PT’s. This includes one four week and two six week, full
time (40 hours per week) clinical experiences where the student must display sufficient skill
and competence to enter the field as a practicing PTA. Students must be willing and able to
organize their time, transportation, and other life responsibilities to complete and benefit
fully from their clinical experiences. Working during the clinical education experience is an
unrealistic expectation.
b. Due to the limited amount of clinical sites and the rural nature of Mohave County, at least
one of these rotations will require the student to travel out of Mohave County for 4 or 6
weeks. All students will complete a student rotation outside of Mohave County, whether you
have children or not.
20. IS THERE A DRESS CODE?
a. Professionalism includes your physical appearance. On campus: program shirts, long pants
or shorts (appropriate length), appropriate footwear (no platform shoes). In clinic: You
must follow the dress code of the clinic. Tattoos must be covered. In lab: shorts, halter
tops, sports bras and athletic shoes for access to body parts and for ease of movement.
21. ARE THE PTA PROGRAM COURSES TRANSFERABLE TO COLLEGES OR UNIVERSITIES IF I DECIDE
TO PURSUE A BACHELOR’S DEGREE?
a. Mohave Community College has a partnership with many universities. Contact college
advising for further information via the Call Center at 866-664-2832. Also, see
www.nau.edu/extended for information about the Bachelor of Science in Health SciencesPhysical Therapist Assisting.
22. PHYSICAL EXAMINATION, IMMUNIZATION AND TB TESTING REQUIREMENTS:
a. A physical examination, proof of immunization and TB testing will be required. Please see
attached (or below whatever works) form. Please be aware that immunization and testing
may vary depending on the clinical site that you may attend during the clinical rotation.
Therefore, additional expenses may occur.
23. BACKGROUND CHECK REQUIREMENTS:
a. Background checks are required for incoming students to insure the safety of the patients
treated by the students in the clinical education program. You will be required to order
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your background check in sufficient time for it to be reviewed by the program coordinator.
A Public Safety Fingerprint Clearance Card (FCC Card) is also required. Students bear the
responsibility for the cost of the Background Check and the FCC Card.
b. For additional information please go to www.mystudentcheck.com, and select Mohave
Community College District from the drop down menu. In the next drop down menu you
will select Physical Therapist Assistant. If you have been advised of being denied entry into
the program due to information on the report, you can contact Pre-Check’s Adverse Action
Hotline at 800-203-1654. This is the procedure by the Fair Credit Reporting Act that
allows you to see the report and to dispute the information. You can also contact
[email protected] for further assistance.
24. DRUG SCREENING
a. Each student must go through a preclinical drug screen prior to beginning the first clinical
rotation. The urine drug screen will test for alcohol; illegal drugs, or drugs that may impair
judgment while working with patients at the clinical site. If the drug test is positive for the
illegal drugs, or drugs that may impair judgment or motor function the student may not be
able to continue in the program. Readmission is at the discretion of the college and the
program director. Some clinical sites also require screening for nicotine. Students who test
positive for nicotine may not be able to be placed at some clinical sites, but are not
excluded from the program.
25. MEDICAL INSURANCE
a. It is a requirement for Mohave Community College PTA students to have medical insurance
while enrolled in this program. Please contact a local insurance provider.
Page 8 of 31
PROGRAM OF STUDY –
PROGRAM REQUIREMENTS: YEAR ONE
*NOTE: Students selected for PTA program must complete BIO 100 BIOLOGY CONCEPTS (4 CREDITS) or
equivalent prior to the start of the fall semester. A grade of C or better must be achieved in all general
education classes to count toward PTA program.
FALL – YEAR ONE
SEMESTER ONE
COURSE
CODE
BIO 201
ENG 101
PTA 101
PTA 103
PTA 200
COURSE NAME
HUMAN ANATOMY & PHYSIOLOGY I
ENGLISH COMPOSITION
SURVEY OF PHYSICAL THERAPY
KINESIOLOGY
PATENT MOBILITY TECHNIQUES
TOTAL CREDITS – YEAR ONE – FALL
CREDIT
S
4
3
3
4
4
18
SPRING – YEAR ONE
SEMESTER TWO
COURSE
CODE
BIO 202
PTA 202
PTA 203
PTA 205
PTA 214
PTA 215
COURSE NAME
HUMAN ANATOMY & PHYSIOLOGY II
PHYSICAL THERAPY MODALITIES
CLINICAL PATHOLOGY
COMMUNICATION IN PHYSICAL THERAPY
ELECTROMODALITIES
WOUND CARE
TOTAL CREDITS – YEAR ONE – SPRING
CREDIT
S
4
5
3
2
3
1
18
SUMMER – YEAR ONE
SEMESTER THREE
COURSE
CODE
PTA 206
PTA 217
CIS 110
COURSE NAME
CLINICAL PRACTICUM I
CLINICAL NEUROLOGY
INTRODUCTION TO COMPUTER
INFORMATION SYSTEMS
TOTAL CREDITS – YEAR ONE – FALL
CREDIT
S
4
2
3
9
Page 9 of 31
PROGRAM OF STUDY –
PROGRAM REQUIREMENTS: YEAR TWO
FALL – YEAR TWO
SEMESTER ONE
COURSE
CODE
COM 121
(OR)
COM 151
PSY 101
PTA 208
PTA 210
PTA 230
COURSE NAME
CREDIT
S
INTERPERSONAL COMMUNICATION (OR)
PUBLIC SPEAKING
3
INTRODUCTION TO PSYCHOLOGY
REHABILITATION OF SPECIAL
POPULATIONS
ORTHOPEDIC PHYSICAL THERAPY
PHYSICAL THERAPY SEMINAR
TOTAL CREDITS – YEAR TWO – FALL
3
5
4
3
18
SPRING – YEAR TWO
SEMESTER TWO
COURSE
CODE
PTA 280
PTA 290
COURSE NAME
CLINICAL PRACTICUM II
CLINICAL PRACTICUM III
TOTAL CREDITS – YEAR TWO – SPRING
CREDIT
S
6
6
12
PTA PROGRAM TOTAL CREDIT HOURS – 75
Page 10 of 31
PROGRAM COSTS
PTA ESTIMATED PROGRAM COST:
IN- STATE COSTS:
Registration Name
Cost Per Credit/Fee
Total Credits/Fee
In – State Cost
Tuition Fee
$
80.00
75
$
6,000.00
Technology Fee
$
6.00
75
$
450.00
Student Life Fee
$
1.00
75
$
75.00
Program Fee
$
7,405.00
1
$
7,405.00
Books Estimate
$
2,100.00
1
$
2,100.00
Estimated Total Cost Of Program
(Based On Estimated $2,100 Book Fee)
$ 16,030.00
OUT- OF - STATE COSTS:
Registration Name
Cost Per Credit
Total Credits/Fee
Out – Of – State Cost
Tuition Fee
$
280.00
75
$ 21,000.00
Technology Fee
$
6.00
75
$
450.00
Student Life Fee
$
1.00
75
$
75.00
Program Fee
$
7,405.00
1
$
7,405.00
Books
$
2,100.00
1
$
2,100.00
Estimated Total Cost Of Program
(Based On Estimated $2,100 Book Fee)
$ 31,030.00
Page 11 of 31
PROGRAM COSTS
PTA ESTIMATED PROGRAM COST PER SEMESTER:
FALL – YEAR ONE
SEMESTER ONE
Registration Name
Cost Per Credit
In-State
Tuition Fee
Technology Fee
Student Life Fee
Program Fee
Books
$
$
$
$
$
Cost Per Credit
Out-Of-State
Total Credits
80.00
$
280.00
18
6.00
$
6.00
18
1.00
$
1.00
18
1,480.00
$
1,480.00
1
500.00
$
500.00
1
Estimated Total Cost Of Program For Semester
In-State
Costs
$1,440.00
$ 108.00
$ 18.00
$1,480.00
$ 500.00
$3,546.00
Out-Of-State
Costs
$
$
$
$
$
$
5,040.00
108.00
18.00
1,480.00
500.00
7,146.00
SPRING – YEAR ONE
SEMESTER TWO
Registration Name
Tuition Fee
Technology Fee
Student Life Fee
Program Fee
Books
Cost Per Credit InState
$
$
$
$
$
80.00
6.00
1.00
1,880.00
500.00
Cost Per Credit
Out-Of-State
$
$
$
$
$
280.00
6.00
1.00
1,880.00
500.00
Total
Credits
18
18
18
1
1
In-State
Costs
Out-Of-State
Costs
$1,440.00
$ 108.00
$ 18.00
$1,880.00
$ 500.00
$
$
$
$
$
5,040.00
108.00
18.00
1,880.00
500.00
$3,946.00
$
7,546.00
SUMMER – YEAR ONE
SEMESTER THREE
Registration Name
Tuition Fee
Technology Fee
Student Life Fee
Program Fee
Books
$
$
$
$
$
80.00
6.00
1.00
810.00
500.00
Cost Per Credit
Out-Of-State
$
$
$
$
$
280.00
6.00
1.00
810.00
500.00
Total
Credits
In-State
Costs
Out-Of-State
Costs
9
9
9
1
1
$ 720.00
$ 54.00
$
9.00
$ 810.00
$ 500.00
$
$
$
$
$
2,520.00
54.00
9.00
810.00
500.00
$2,093.00
$
3,893.00
Page 12 of 31
PROGRAM COSTS
PTA ESTIMATED PROGRAM COST PER SEMESTER:
FALL – YEAR TWO
SEMESTER ONE
Registration Name
Cost Per Credit
Out-Of-State
Total
Credits
In-State Costs
Out-Of-State
Costs
Tuition Fee
$80.00
$280.00
18
$1,440.00
$5,040.00
Technology Fee
$6.00
$6.00
18
$108.00
$108.00
Student Life Fee
$1.00
$1.00
18
$18.00
$18.00
$1,615.00
1
$1,615.00
$1,615.00
$500.00
1
$500.00
$500.00
$3,681.00
$7,281.00
Program Fee
$1,615.00
Books
$500.00
SPRING – YEAR TWO
SEMESTER TWO
Registration Name
Tuition Fee
Technology Fee
Student Life Fee
Program Fee
Books
$
$
$
$
$
80.00
6.00
1.00
1,620.00
100.00
Cost Per Credit
Out-Of-State
$
$
$
$
$
280.00
6.00
1.00
1,620.00
100.00
Total
Credits
12
12
12
1
1
In-State
Costs
Out-Of-State
Costs
$ 960.00
$ 72.00
$ 12.00
$1,620.00
$ 100.00
$
$
$
$
$
3,360.00
72.00
12.00
1,620.00
100.00
$2,764.00
$
5,164.00
PTA PROGRAM TOTAL CREDIT HOURS – 75
Page 13 of 31
CLINICAL NEEDS CHECK LIST
This is only a checklist, please do not have the physician sign or stamp this form.
It is the student’s responsibility to provide proof of the following to the program secretary before the end of the first
semester for clinical practicum placement. Updates must be provided 30 days prior to starting each clinical
practicum throughout the PTA Program. Individual clinical needs documents will not be accepted until check list is
complete. Please turn in a completed packet of clinical needs documents from the checklist when completed.
STUDENT ID #
AGE
FIRST NAME
MALE
MIDDLE INITIAL
 FINGERPRINT CLEARANCE CARD – AZ Department of
Public Safety. Fingerprint card is good for 6 years.
Date: ___________________________________
 HEALTH INSURANCE – Student’s personal health care
insurance. You must provide your own health insurance.
Date: ___________________________________
 PHYSICAL – Student’s healthcare provider. Physical is
good for the duration of the program.
Date: ___________________________________
 DRUG SCREENING – PTA DEPARTMENT WILL PAY FOR
YOUR SCREENING. Do not make an appointment for
this. Sonora Quest Laboratories form 30 days prior to
clinical placement.
Date: ___________________________________
 ANNUAL TB TEST – If you have never had a TB Test you
will need the 2-Step TB. Annual TB test is good for 1 year.
If you have had a chest x-ray that is good for two years.
LAST NAME
Process for 2-Step TB – The 1st step is an injection from
your health care provider followed up with a reading 2-3
days after the injection. The 2nd step repeats the process
1-3 weeks after the 1st reading. 2-step TB is not complete
until the second test is read. 2-StepTB test is good for 2
years.
Date: _____________________________
 BACKGROUND CHECK – Pre-check form. Background
check is good for the duration of the program.
Date: ___________________________________
 HEALTH CARE PROVIDER CPR – Must be obtained
through either the American Red Cross or the American
Heart Association, classes offered through Community
Outreach program at MCC. CPR is good for 2 years.
Date: ___________________________________
FEMALE
 HEP B OR TITER – (optional but highly recommended - if
titer is low or no immunity you will need the HEP B vaccine
or you must sign a declination form) Hepatitis B is
contracted from blood borne pathogens. HEP B is good for
7 - 10 years. Booster recommended after 10 years.
Three immunization series –
1. 1st injection of vaccine
Date: ___________________________________
2.
2nd injection is administered 30 days after 1st injection.
Date: ___________________________________
3.
3rd injection administered at the end of the 5th month.
Date: ___________________________________
All 3 vaccinations must be completed in order to obtain
full immunity.
 VARICELLA (chicken pox) OR TITER – (if titer is low or
no immunity you will need the Varicella vaccine) this
vaccine is good for 10 years.
Date: ___________________________________
 MMR (Measles, Mumps, and Rubella) OR TITER – (if titer
is low or no immunity you will need the MMR vaccine) this
vaccine is good for 10 years.
Date: ___________________________________
Page 14 of 31
PHYSICAL EXAMINATION FORM
Student Name:
“STUDENT USE ONLY”
(Student must complete this side)
Social Security#:
/
/
Address:
City:
Home Phone:
State:
Zip:
Cell Phone:
Physical Therapist Assistant (PTA) Student Qualifications
A physical therapist assistant student MUST be able to perform the following functions:
1. Stand and walk continuously for up to eight hours.
2. Visual acuity and depth perception to read physical therapist orders.
3. Hearing acuity and to hear machine alarms, announcements on PA systems, normal conversations, and through
stethoscopes.
4. Safely handle blood and other body excretions and secretions.
5. Perform basic resuscitation and emergency procedures according to CPR protocols.
6. Lift, move, position, and otherwise handle patients to minimize discomfort and provide basic care.
7. Ability to lift 50 pounds.
8. Lift, move, and operate equipment used in the care of patients.
9. Assist with or administer treatments and therapies using potentially hazardous equipment (i.e. needles, caustic
drugs, X-rays).
10. Manual dexterity to manipulate syringes, vials, pills, buckle and unbuckle, apply dressings and binders.
11. Psychological stability to perform effectively under stress.
12. Ability to exercise critical thinking reasoning and judgment in a client care situation.
Understanding of Requirements
As a physical therapist assistant student of MCC, I understand I must be able to meet the above physical requirements. I have
read and understand the requirements, and I am able to perform all the above listed functions.
As a physical therapist assistant student of MCC, I understand that I must provide the following requirements:
1) Proof of current vaccinations or verification of immunity through positive titer’s
a. MMR
b. Varicella
c. Hepatitis B Series
2) Negative TB (2-step) or Chest X-ray
3) Current CPR certification (Heartsaver, Adult or Community CPR is not acceptable)
4) Negative Drug screen (positive results must be followed up with verifiable proof of prescriptions)
5) Current Physical Examination provided by a physician found on the back of this form
As a physical therapist assistant student of MCC, I understand that failure to provide CURRENT documentation will result in
dismissal from the physical therapist assistant program.
COMMENTS:
Student Name (please print):
Date:
Student Signature:
Page 15 of 31
“PHYSICIAN USE ONLY”
(Physician must complete this side)
STUDENT NAME:
HEENT:
Lungs:
Vital Signs:
VISION:
Heart:
Extremities/Joints:
(R)
(L)
Abdomen:
Neurological/Mental:
CORRECTED:
(R)
(L)
Please list all prescription medications being used by the student and the reason:
Please list all chronic conditions or medical problems the client has:
Record of Immunizations: (PROOF is required for all Immunizations or Titers)
Clinical sites utilized for MCC physical therapist assistant student Clinical Experiences require proof of all of the following
Immunizations or tests. Students will only be allowed an exception based on a medical condition and a physician’s note is
required.
MMR
Varicella
Date:
Date:
Date:
Influenza
(or) Positive
(or)
Positive
Titers
(Required for NUR
(Annual)
Titer
Titer
Date:
Titers Date:
III ONLY)
Hepatitis B Series
(or) status of
Immunity
With a Titer
Date:
Date:
#3. Date:
Titers Date:
#1.
TB Skin Test
Negative (2-Step)
(or) Negative X-Ray
#2.
Date:
Date:
X-Ray Date:
#1.
#2.
Physical Therapist Assistant Student Qualifications
A physical therapist assistant student must be able to perform the following functions:
1. Stand and walk continuously for up to eight hours.
2. Visual acuity and depth perception to read doctor’s orders and medical dosages on syringes and vials.
3. Hearing acuity to hear machine alarms, announcements on PA systems, normal conversations, and through stethoscopes.
4. Safely handle blood and other body excretions and secretions.
5. Perform basic resuscitation and emergency procedures according to CPR protocols.
6. Lift, move, position, and otherwise handle patients to minimize discomfort and provide basic care.
7. Ability to lift 50 pounds.
8. Lift, move, and operate equipment used in the care of patients.
9. Assist with or administer treatments and therapies using potentially hazardous equipment (i.e. needles, caustic drugs, Xrays.)
10. Manual dexterity to manipulate syringes, vials, pills, buckle and unbuckle, apply dressings and binders.
11. Psychological stability to perform effectively under stress.
12. Ability to exercise thinking, reasoning and judgment in a client care situation.
Physicians Signature of Authorization
Based on this physical examination, do you find this person capable of performing ALL of these functions
without ANY reservations?
YES:
(If No, Please Explain):
Physician Name (please print):
Date:
Physician Signature:
Address:
NO:
Telephone:
City:
State:
Zip:
Page 16 of 31
MOHAVE COUNTY
DEPARTMENT OF PUBLIC HEALTH
Health Department
2001 College Drive
Lake Havasu City, AZ 86403
Phone: 928-453-0703
Fax: 928-453-0740
ADULT IMMUNIZATIONS:
2014 PRICING
TD (TETANUS/DIPHTHERIA
HEPATITIS A
HEPATITIS B
MMR
VARICELLA
MENACTRA (MENINGOCOCCAL
VACCINE)
MENOMUNE (MENINGOCOCCAL
VACCINE)
TWINRIX (HEPATITIS A AND B
COMBINED)
RABIES (IMOVAX)
ADACEL (ADULT PERTUSSIS) T DAP
INFLUENZA
PNEUMONIA
HEP B TITER
VARICELLA TITER
MEASLES - RUBELLA TITER
RABIES TITER
HPV
SHINGLES


$52.00
$64.00
$72.00
$93.00
$131.00
$155.00
$154.00
$92.00
$272.00
$70.00
$37.00
$98.00
$81.00
$87.00
$158.00
$118.00
$178.00
$211.00
These services offered on sliding fee scale based upon patient income
If you are 18 years old and have no insurance coverage for vaccines you can be seen for
free on kid’s day (Tuesday’s).
2014 Current Mohave County/Public Health pricing for adult services
Page 17 of 31
APPLICATION PACKET
Application Period: January 5th, 2015 – April 24th, 2015
(Application Deadline is April 24th, 2015)
2014-15 Academic Year
Page 18 of 31
APPLICATION CHECKLIST
Please follow these steps in the order they are presented:
BECOME AN MCC STUDENTComplete the online admissions application at:
https://jics.mohave.edu/ICS/Admissions_Apply_Online/Home.jnz
TRANSCRIPTS –
1. Hard copy of your COMPASS test results (if taken).
2. ALL OFFICIAL transcripts from colleges/universities AND high school transcript (OR GED
scores) to be sent to:
Liz Briere, PT, DPT
Director, PTA Program
1977 W Acoma Blvd
IMPORTANT NOTE: Transcripts must be sent from previous institutions directly to MCC to
be considered official. Please allow 2 weeks for receipt of transcripts. The program can retrieve
your MCC transcripts, it is not necessary to request MCC transcripts.
OBSERVATION HOURS –
Include observation hour’s form after completing observation hours.
It is required that you complete 12 hours in-patient and 12 hours out-patient.
Some physical therapy sites do not allow you to observe until you have spoken to the Program Director.
PRE-CHECK CRIMINAL BACKGROUND CHECK –
Obtain Pre-Check Criminal Background Check (www.mystudentcheck.com). After the Pre-Check
Criminal Background check has been cleared, select school – Mohave Community College district,
PTA. Complete remaining application online.
HOBET TEST –
HOBET Entrance Examination can be taken at any MCC campus in the testing center. You can
schedule this test inside student services. You will need to print out a copy of the exam results and
include it with the application. (http://www.mohave.edu/resources/testing)
HEALTHCARE PROVIDER CPR CERTIFICATION –
Proof of healthcare provider CPR certification. You can sign up from a list of courses offered at
anyone one of MCC’s four campuses through community education program.
(http://www.mohave.edu/community/communityeducation)
OPEN HOUSE –
Attend PTA Applicant Open House. This is mandatory and by invitation only to those individuals
qualified to continue in the application process. Once your application has been reviewed and the
program director determines you are eligible to move to the next step, you will be sent an invitation
to the open house.
Page 19 of 31
Application Period: January 5th, 2015 – April 24th, 2015 (Application Deadline is April 24th, 2015)
ADMISSION REQUIREMENTS AND SELECTION CRITERIA:

APPLICATION REQUIREMENTS CHECKLIST
MCC’s Online Admissions Application
PTA Program Application
Admissions Application Disclaimer Signature Page
Drug Screening and Criminal Background Self-Disclosure Signature Page
Essential Functions and Understanding of requirements Signature Page
Proof of college level reading and math skills via the Compass Test or Transcripts
High School Transcripts OR GED scores.
All Official College Transcripts (if any) – Official transcripts are sent from Institution
to Institution. Transcripts mailed to the student are considered unofficial.
Demonstrate an overall GPA of 2.7
Demonstrate a minimum GPA of 2.7 in BIO 100
PreCheck Criminal Background Check
Proof of CPR Certification – Healthcare Provider level
24 Observation Hours
HOBET Entrance Examination
SELECTION CRITERIA – POINTS WILL BE GIVEN FOR THE FOLLOWING
CRITERIA:
COURSES
A
B
C
Points

PREREQUISITES
GENERAL EDUCATION
BIO 100
BIO 201
BIO 202
PSY 101
COM 121
or 151
ENG 101
CIS 110
HEALTH OCCUPATIONS BASIC
ENTRANCE TEST (HOBET V)



3
3
3
3
2
2
2
2
1
1
1
1
3
2
1
3
2
3
2
5 points 50%
to 60%
RESIDENCY
County Resident
Arizona Resident
WORK EXPERIENCE
PT Related
Healthcare Related
ADDITIONAL COURSE COMPLETION POINTS
Completion of 5 to 6 of the above prerequisites & general
education
education
education
1
1
10 points 61%
to 100%
Points
2
2
Points
7
5
Points
Points
Points
Points
10
6
2
TOTAL POINTS: _______________
*NOTE: in the case of a tie, the application admitted the earliest would receive a place in the program.
Page 20 of 31
APPLICATION
If you have any physical or mental impairment contact:
Disability Services:
(928) 680–5946
PLEASE PRINT OR TYPE
Name: ____________________________________________________________________________________
Former name(s) which may appear on transcripts: ________________________________________________
Are you currently enrolled at MCC?
YES
or
NO
(Please Circle Yes or No)
Student ID # or Last 4 of Social Security Number: __________________
Home Address: _____________________________________________________________________________
City: _________________________________________________ State: _________ Zip __________________
Home Phone: ___________________________ Work/Cell Phone: ___________________________________
Email: __________________________________________________________________
WORK EXPERIENCE:
(LAST 5 YEARS, BEGINNING WITH MOST RECENT)
EMPLOYER
POSITION
DATES
PHONE
REASON FOR
LEAVING
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
NOTE: It is the applicant’s responsibility to assure that the information on this application remains current.
Page 21 of 31
ADMISSION APPLICATION DISCLAIMER
Your admission to the Mohave Community College Physical Therapist Assistant Program does not
guarantee you will receive an Associate in Applied Science Degree from the College. Further, completion
of the Physical Therapist Assistant Program is not the sole criterion for obtaining a license/certificate to
practice. Licensing/certification requirements are the exclusive responsibility of the individual State
Boards of Physical Therapy or similar agencies, and you must satisfy those requirements independently of
MCC.
CERTIFICATION:
I hereby certify that the facts set forth in this student application are true and complete to the best of my
knowledge. I understand that if accepted, any falsified statements on this application shall be considered
sufficient cause for suspension or dismissal.
CLINICAL EXPERIENCE:
MCC Physical Therapist Assistant students will be required to travel outside of Mohave County for a portion
of their clinical experience. I understand that if accepted into the Physical Therapist Assistant Program, I
will be required to travel for these clinical experiences and that I will be responsible for my own housing,
transportation and meals.
I understand that if accepted, I will be required to meet the health requirements of the Physical Therapist
Assistant Program.
__________________________________________________
Applicant’s Name (PRINT)
__________________________________________________
Applicant’s Signature
_______________________________________
Date
SUBMIT TO: Mohave Community College
Liz Briere, PT, DPT
1977 W Acoma Blvd
Phone: 928-505-3347
[email protected]
Page 22 of 31
DRUG SCREENING
Drug Screening - Each student must go through a preclinical drug screen prior to beginning the first clinical
rotation. The urine drug screen will test for alcohol; illegal drugs, or drugs that may impair judgment while
working with patients at the clinical site. If the drug test is positive for the illegal drugs, or drugs that may
impair judgment or motor function the student may not be able to continue in the program. Readmission
is at the discretion of the college and the program director. Some clinical sites also require screening for
nicotine. Students who test positive for nicotine may not be able to be placed at some clinical sites, but are
not excluded from the program.
CRIMINAL BACKGROUND SELF-DISCLOSURE
Criminal Background Self-Disclosure -- Prior conviction of a felony or certain misdemeanors, other than
minor traffic offenses, may make a student ineligible to participate in various clinical experiences and
possibly make it impossible for a student to complete the scheduled program of study. Prior conviction of
a felony or misdemeanor may make the individual ineligible for professional licensure, professional
certification, or professional registration, dependent on specific regulations of individual state of practice.
Please Note: Convictions or charges resulting in any of the following must be reported: plea of guilty, plea
of nolo contendere (no contest), withheld or deferred adjudication, suspended or stay of sentence, and/or
military court martial.
HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR OR A FELONY? Misdemeanor charges or
convictions that occurred while a juvenile and that were processed through the juvenile court system are
not required to be reported. Misdemeanor speeding convictions are not required to be reported unless
they are related to alcohol or drug use.
1. Have You Ever Been Convicted of a Misdemeanor or a Felony? Circle One:
Yes
No
2. If response is YES, list all offenses, dates, locations of courts, and outcomes. Official court
documentation may be required by the licensing agency.
My statement regarding my criminal background is accurate to the best of my knowledge. I understand the
falsification or omission of information may result in disqualification or dismissal of this application for
admission to Mohave Community College Physical Therapist Assistant Program.
I hereby certify that the statements on this application are correct to the best of my knowledge and I
understand that falsification or omission of information may result in disqualification or dismissal of this
application for admission to Mohave Community College Physical Therapist Assistant Program. I authorize
official representatives of Mohave Community College Physical Therapist Assistant Program to verify
information provided in this application. Application materials submitted as part of the application
process, become the property of Mohave Community College Physical Therapist Assistant Program.
Materials will not be returned, and copies will not be provided. I agree to abide by the policies and
regulations of Mohave Community College Physical Therapist Assistant Program.
Page 23 of 31
DRUG SCREENING
Note 1: Please keep a copy for your records.
Note 2: Drug screening will be required of students as a condition of eligibility to participate in clinical
practicum. Be advised that a positive result on a drug test will result in consequences that will vary
depending on the level of severity and the need for additional treatment. At the very least the student will
be unable to attend a clinical or field site until cleared to do so. Other potential consequences may include
suspension or expulsion.
____________________________________
______________________________________
_____________________________
Date
SUBMIT TO: Mohave Community College
Liz Briere, PT, DPT
1977 W Acoma Blvd
Phone: 928-505-3347
[email protected]
Page 24 of 31
MOHAVE COMMUNITY COLLEGE
PHYSICAL THERAPIST ASSISTANT
ESSENTIAL FUNCTIONS
THE FOLLOWING IS A LIST OF PHYSICAL AND MENTAL JOB EXPECTATIONS FOR A PHYSICAL
THERAPIST ASSISTANT:
A physical therapist assistant student MUST be able to perform the following functions:
1. Demonstrate visual acuity and auditory ability to assess the condition of a patient and
administer effective patient care.
2. Demonstrate manual dexterity, eye-hand coordination, fine and gross motor skills, and tactile
abilities to perform functions as directed by the physical therapist and in accordance with the
Evaluative Criteria for the Accreditation of Physical Therapist Assistant Education Programs
(http://www.apta.org/CCIP/).
3. Demonstrate critical thinking and problem solving skills for effective patient management and
implementation of selected treatment interventions.
4. Maneuver equipment in a patient’s room or in the physical therapy department.
5. Work in stressful situations that require quick thinking and the simultaneous coordination of a
variety of activities.
6. Demonstrate physical agility to respond to patient and family needs, including unexpected
changes in the patient’s status.
7. Demonstrate the physical ability to assist patients in ambulating, positioning in bed, and
transferring from the bed/mat, wheelchair or car.
8. Demonstrate proper body mechanics for lifting.
9. Lift objects in excess of 100 pounds with assistance with frequent lifting and/or carrying objects
weighing 50 pounds or more.
10. Tolerate prolonged standing, stooping, squatting, bending, pushing, and pulling.
11. Demonstrate ability to read, write, understand and speak English.
12. Demonstrate effective verbal and non-verbal communication skills with internal and external
customers.
Graduates who are unable to perform these functions, with or without reasonable accommodations, may
be unsafe and unsuccessful as a provider of physical therapy services.
EQUAL OPPORTUNITY POLICY STATEMENT
Mohave Community College does not discriminate on the basis of sex, color, race, religious preference, age,
disability, national origin, Veteran status or any other legally protected class in any of its policies, practices,
and procedures, and it is an affirmative action and equal opportunity employer. For more information, call
the Human Resources Office at 928.757.0835, 1971 Jagerson Ave., Kingman, AZ 86409. Grievance
procedures are available at the Mohave Community College libraries in Bullhead City, Colorado City,
Kingman and Lake Havasu City.
Page 25 of 31
UNDERSTANDING OF REQUIREMENTS
As a physical therapist assistant student of MCC, I understand I must be able to meet the above physical
requirements. I have read and understand the requirements, and I am able to perform all the above
listed functions.
As a physical therapist assistant student of MCC, I understand that I must provide the following
requirements:
6) Proof of current vaccinations or verification of immunity through positive titer’s
7) MMR, Varicella, Hepatitis B Series, Negative TB (2-step) or Chest X-ray
8) Current CPR certification (Heart Saver, Adult or Community CPR is not acceptable)
9) Negative Drug screen (positive results must be followed up with verifiable proof of prescriptions)
10)Current Physical Examination provided by a physician found on the next form
As a physical therapist assistant student of MCC, I understand that failure to provide CURRENT
documentation will result in dismissal from the physical therapist assistant program.
_____________________________________________________
_____________________________________________________
____________________________________________
Date
Page 26 of 31
OBSERVATION HOURS
Twenty Four (24) hours of observation are required prior to application for admission into the Physical
Therapist Assistant (PTA) Program at Mohave Community College. The requirement assures that the
applicant has done career exploration in the field. Additionally, the program wants to be reasonably certain
that students entering the program are committed to this career goal. The applicant should expect that the
majority of facilities allow volunteers “observation only” of physical therapy practice. “Hands on”
experience is not allowed in most facilities.
It is the responsibility of the student to arrange for observation hours and/or to certify work experience
gained in the field. Facilities may have a waiting list for volunteers and may have limited hours in which
volunteers can be accommodated Allow several weeks to find a facility or facilities when you plan to
complete the observation hours. A list of local facilities has been included in the packet for your
convenience.
OBSERVATION HOURS VERIFICATION FORM
INSTRUCTIONS TO THE APPLICANT
The observation form is located in the application packet. Only DIRECT observation in PHYSICAL
THERAPY will satisfy the prerequisite requirement. Observation must have occurred within the past two
years. Make additional copies of this form if your observation hours have been performed in more than
one facility. A separate form should be provided to each facility.
Appropriate dress is recommended. Closed toed shoes, slacks (nice khakis are acceptable), polo-type or
similar shirt. Please do not wear sandals, halters, shorts, jeans, capris or any tight fitting clothing.
Undergarments should not be seen. Long hair should be pulled back, minimal jewelry, and nails must be
clean and fingertip length. Perfume, cologne and visible tattoos should be minimal. The facility has the
right to turn you away for inappropriate appearance.
Page 27 of 31
OBSERVATION HOURS
(REQUIRED)
Please call ahead. Each facility has different requirements for job shadowing. Ask for either the
volunteer office or the physical therapy department to schedule job shadowing. Be aware it does take
extra time to arrange hours at some facilities. Immunization may be required prior to observation at
some sites. This list is not conclusive of all rehab facilities in the tri-state area.
ARIZONA
Havasu Regional Medical Center
LHC
IP/OP
Lakeside Physical Therapy & Rehab.
LHC
Outpatient
PRO Therapy
LHC
Outpatient
TruRehab
LHC
Outpatient
Valley View Medical Center
Ft. Mohave
IP/OP
Palo Verde Physical Therapy
Willmore Wellness
Bullhead City
Bullhead City
Western Arizona Regional Medical Center
River Gardens
Bullhead City
Bullhead City
928-453-0411
928-855-4248
928-854-4776
928-453-0501
928-788-3604
Outpatient
928-758-0029
Outpatient
928-763-0807
IP/OP
928-763-0252
Inpatient
928-763-8700
Deering Physical & Occupational Therapy
Kingman
Outpatient
Kingman Regional Medical Center
Kingman
IP/OP
Physiotherapy Associates
Kingman
Outpatient
Gardens Care Center
Kingman
Inpatient
928-753-4263
928-692-4635
928-757-1211
928-718-0718
IP/OP = Facility has inpatient and outpatient available
Page 28 of 31
OBSERVATION HOURS VERIFICATION
STUDENT NAME _____________________________
Note to Supervisor: The above named student is performing this task in anticipation of enrolling in the PTA
program at Mohave Community College. Thank you for your support.
The physical therapy volunteer/observation certified on this form can best be described as occurring in
the following setting:
*NOTE:
A total of twenty four (24) hours is required from both inpatient (12 hours) and
outpatient settings (12 hours). A (*) denotes site is acceptable as an inpatient setting.
If several types of experiences were provided at one facility, please specify the number of
hours spent in each type of experience.
HOURS
NAME OF FACILITY
SIGNATURE/LICENSE #
_______ Acute Care Hospital*
______________
__________________
_______ Rehab Unit (Hospital Based)*
______________
__________________
_______ Rehab Unit (Free Standing)*
______________
__________________
_______ Outpatient Services (Hospital Based)
______________
__________________
_______Private Practice
______________
__________________
_______ Sports Medicine
______________
__________________
_______ Extended Care Facility (NH/SNF)*
______________
__________________
_______ Industrial Injury Rehabilitation Clinic
______________
__________________
_______ Home care
______________
__________________
_______ Pediatric Care
______________
__________________
_______School Based Physical Therapy
______________
__________________
_______ Cardiac Rehabilitation
______________
__________________
_______ Other (Please specify)
______________
__________________
INSTRUCTIONS TO SUPERVISOR: Please sign on the line for the setting where you supervised the student’s
hours. Please contact the PTA Program Director at Mohave Community College, with any questions or
concerns about this experience (928-505-3347).
INSTRUCTIONS TO STUDENT: Please submit this form with your application paperwork. A background
check may be required by the facility prior to completion of the observation hours.
Page 29 of 31
BACKGROUND CHECKS
I understand that a positive result on the background check could preclude me from clinical affiliations at
certain facilities since each clinical site has their own criteria. I also understand that this could affect my
ability to graduate from the program. In addition, I understand that a positive background check will need
to be addressed with the state board of physical therapy and that it may preclude me from obtaining a state
license to practice as a Physical Therapist Assistant.
___________________________________
SIGNATURE
_________________________
DATE
_________________________________________
PRINTED NAME
FINGERPRINT CARDS
I, ______________________________, understand that I must present a valid AZ DPS fingerprint card in order to
participate in all clinical education experiences. I must report any incident to the program within 7 days
that may affect my status. If I am on a clinical experience, I have 24 hours to report the incident to the
program.
I acknowledge failure to maintain a valid Fingerprint Card may also be cause for dismissal from the
program.
______________________________________ _________________________
SIGNATURE
DATE
_________________________________________
PRINTED NAME
(Please sign and return with completed application)
Page 30 of 31
STUDENT DEMOGRAPHIC INFORMATION
DATE: __________________________________________
GENDER:
MALE
FEMALE
AGE: ___________
ETHNIC ORIGIN: (PLEASE CHECK ONE)
AFRICAN-AMERICAN/BLACK (NON-HISPANIC)
AMERICAN INDIAN/ALASKAN NATIVE
ASIAN/PACIFIC ISLANDER
HISPANIC/LATINO
WHITE (NOT OF HISPANIC ORIGIN)
OTHER:
CHECK PRIOR DEGREE/S EARNED:
ASSOCIATES
BACHELORS
MASTERS
DOCTORAL
NONE
Page 31 of 31

Program Information Manual Physical Therapist Assistant Program

Transcription

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