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Blinn College PTA Program
Documentation of Physical Therapy Experience Form
Important: In order to meet the requirements for application, all applicants must provide a valid email address to complete an evaluation for each facility where the student has shadowed.
Student Name
Facility Name
Facility Address
Type of Setting
(Circle all that apply)
Acute care / Hospital Outpatient Skilled Nursing
Aquatics Inpatient Rehab Pediatrics Home Health
Experience Dates and Times
| Date | Time In | Time Out | Total Time |
|---|---|---|---|
Total Hours:
Therapist Verification
Therapist Signature
Therapist Printed Name
Therapist or Clinic Email