SUPERVISING PHYSICAL THERAPIST RECOMMENDATION & PARTNERING AGREEMENT FORM

Application for Advanced Proficiency Pathways for the PTA

The following applicant,, is applying for Advanced Proficiency Pathway in physical therapy.

Please answer the following questions and complete the recommendation rubric.

How long have your worked with the applicant?

The applicant …

/ Strongly
Agree / Agree / Disagree / Strongly
Disagree
Demonstrates at least entry-level knowledge in patient/client interventions and related data collection.
Demonstrates at least entry-level skill competence in patient/client interventions and related data collection.
Demonstrates willingness to increase knowledge and skill performance in the selected Advanced Proficiency Pathway content area.
Demonstrates ability to develop additional knowledge and skill in the selected Advanced Proficiency Pathway content area.
Assumes responsibility for educational and career development.
Acquires knowledge in a self-directed and focused manner.
Demonstrates values through behaviors that are consistent with the Values-based Behaviors for the PTA.
Actively collaborates with the physical therapist, patient/client, and other members of the health care team.
Demonstrates potential for growth and development in the areas of advocacy and leadership.
Has a history of completing projects and assignments without prompting.

Additional Comments:

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Advanced Proficiency Pathway Partnering Agreement

I understand that the applicant must meet all of the requirements of the Advanced Proficiency Pathway to earn his/her Certificate of Advanced Proficiency in ______Physical Therapy, including:

1.60 contact hours of selected continuing education courses that meet the defined guidelines and content of the APP, including:

  • APTA ‘core’ courses
  • Selected content courses or equivalent APTA approved courses

2.Mentored clinical experiences* with the supervising physical therapist and clinical mentor

3.2000 clinical hours of work experience in the content area

4.Successful completion of all competency-based assessments, including

  • Knowledge assessment via course examinations; and
  • Skill assessment via skill checks by the clinical mentor

By signing and submitting this reference, I am agreeing to assist the applicant in completing the Advanced Proficiency Pathway, and agree to the following in order to accomplish that goal:

  • I understand that I may be asked to provide clinical mentoring, selected clinical experiences, relief time for clinical mentoring, and/or professional and/or personal support to the applicant; all as permitted by facility and regulatory guidelines.
  • I will demonstrate professional behaviors and provide opportunities as they arise for the applicant to develop skills in advocacy, leadership, and mentoring.
  • I will promote enhanced PT-PTA collaboration, including communication and documentation.
  • I will review and sign-off on applicant’s submitted total work hours in the content area of the Advanced Proficiency Pathway at the conclusion of the program.

Signature (electronic signatures are acceptable):

Facility:

Preferred contact phone: ()

Preferred contact e-mail address:

Please e-mailthis completed reference and agreement form to by the appropriate enrollment due date. Thank you.

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