Physical Therapist Assistant Program Volunteer/Observation Evaluation Dear Clinician, Thank you for allowing this applicant to observe (or work) in your facility as part of their preparation for admission to the UAA PTA program. Each applicant is required to complete a minimum of 15 hours of work or observation in two different types of physical therapy settings to help the applicant learn about the profession and to see what PTs/PTAs do. They may observe either a PT or PTA. Using the form provided on the next page, please evaluate this applicant on his/her professional behavior during their experience in your facility. Please complete only one form per facility if you are able to offer multiple types of physical therapy exposure. Please sign the form at the bottom and return it to the applicant in a sealed envelope with your name written across the seal. Thank you so much for your invaluable assistance to the program and the profession. Physical Therapist Assistant Program Volunteer/Observation Evaluation Form  By checking this box, the applicant waives his/her right to read the completed observation form. If the box is not marked, you must assume that the applicant will be allowed to review the completed form. Applicant Name (type or print name):
is seeking admission to the UAA PTA program. Your cooperation in completing and promptly returning this recommendation form will assist both the applicant and the PTA program in the admission process. The student has indicated above if he/she waives the right to review this recommendation form. Applicant’s Name: ______________________________ Name of facility: _______________________ Clinical Setting(s): ______________________________ Number of hours in facility: ______________ Please circle your response using the following key: 5 = strongly agree 4= agree 2 = disagree 3 = neutral 1 = strongly disagree 1.
The applicant was courteous and professional in interactions with staff, patients and others. 5
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The applicant was consistently punctual and arrived as scheduled. The applicant was appropriately attentive and demonstrated a commitment to learning about the field. The applicant showed concern and respect for patients/clients.
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The applicant was appropriately dressed and projected a professional image during this observation or work experience. The applicant demonstrated respect for authority and complied with instructions given during this observation or work experience. 5
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☐Highly Recommend ☐ Recommend ☐ Uncertain ☐ Do not recommend ☐Other Please provide any comments below or on the back of this page that would help the admissions committee understand the specific strengths of and/or areas of concern that you would have about this student. _____________________________ ______________________________ __________ Clinician Signature Printed Name/Title Date