UNIVERSITY OF EVANSVILLE

Doctor of Physical Therapy Program Application

Term of Entry: Summer 2015

Application must be typed. Application deadline is October 15, 2014.

1. Name

LastFirst Middle Maiden

2. Gender

Male / Female

3.Permanent Address

Street City State Zip

Campus Address

Street City State Zip

4. Telephone (include area code)Cell Phone

5.Social Security Number UE ID (if applicable)

6. Birth Date (include month, date, year) Age

7. Marital Status

8. E-mail

9. Planning to commute or live on campus?

Commute / Live on Campus

10. Are you a dependent of a University of Evansville employee?

Yes / No

11.Are you a United States citizen?

Yes / No

If you are not a United States citizen, are you a permanent resident?

Yes / No

Country of Citizenship

12. Race (optional)

Please select one or more of the following racial categories to describe yourself:

African American or Black

American Indian or Alaskan Native

Asian

Caucasian or White

Hispanic/Latino

Native Hawaiian or other Pacific Islander

13.High school attended

Name City State Year ofGraduation

14. SAT Scores

Verbal/Critical ReadingMath Written

ACT Score

15. List all colleges/universities attended.List the college/university where you completed or anticipate completing your bachelor’s degree first.

a.

College/University

Location

Dates of Attendance

MajorDate or Anticipated Date of Bachelor’s Degree Completion

b.

College/University

Location

Dates of Attendance

MajorDegree

c.

College/University

Location

Dates of Attendance

MajorDegree

16. List honors or special awards received while attending college.

Award Date

1.
2.
3.
4.

17. If you have graduated with your bachelor’s degree, describe your employment history and/or other activities

in which you have been involved since receiving your degree.

Employment/Activities Dates

1.
2.
3.
4.
5.

18. List your extracurricular, community and volunteer activities unrelated to physical therapywhich

demonstrate leadership.

Activity Dates

1.
2.
3.
4.
5.

19. If you have been employed while in college, specify your employment history, hours worked per week, and the

dates.

Place of Employment Hours/Week Dates

1.
2.
3.
4.
5.

20. List the prerequisite courses in which you are enrolledfor fall semester 2014.

CollegeCourse Name and Number Semester Hours Quarter Hours

1.
2.
3.
4.

21.List the prerequisite courses you plan to take duringspring semester 2015. All prerequisites, with the

exception of Medical Terminology, must be successfully completed prior to the start oftheDPT program.

CollegeCourse Semester HoursQuarter Hours

1.
2.
3.
4.

22. List your observation, volunteer or employment activities in physical therapy settings.

Dates Facility Types of Patients Total Name of

Observed Hours Therapist

1.
2.
3.
4.
5.
6.

23. Attach a separate typed paragraph describing other activities you have completed, in addition to volunteer

and employment, to explore the physical therapy profession.

24. Two prerequisites courses may be repeated (excluding Medical Terminology). Please indicate the

prerequisite course(s) you repeated, including both the original gradeand the grade of the repeated course

that the Selection Committee should consider.

Course Institution Year Original Grade Repeat Grade

1.
2.

25.List any prerequisite course in which you earned a W.

Course Name and Number Institution Year

1.
2.
3.
4.

26.Essay

Choose one of the American Physical Therapy Association’s (APTA) Core Values as defined by the APTA and write an essay that describes how the physical therapist(s) you have observed demonstrated this value. The essay must be a minimum of 250 words, double-spaced and limited to two single-side pages with one inch margins top, bottom and sides, in 12-point type. Please sign the completed essay.Plagiarism is considered a serious offense at the University of Evansville. If it is determined that your essay has been plagiarized or purchased, you will be eliminated from consideration for the program.

*Have you ever been convicted of, plead guilty to or nolo contendre to any offense, misdemeanor or felony in any state or do you have charges pending for which you could be convicted (except for minor traffic violations resulting in fines). If yes, please explain in an attached letter.
Yes
No
Have you ever been dismissed from a high school, college or university for disciplinary reasons? If yes, please explain in an attached letter.
Yes
No
Submission of your application certifies that all information providedis complete and accurate to the best of my knowledge. I understand that concealment of relevant information or falsification of information may lead to my not being selected for the Doctor of Physical Therapy program or removal from the program at any time in the future.
Signature ______Date______
*A criminal background checkis required as a condition of admission and annually for all students in the program. A positive result may prohibit a student from admission into the Doctor of Physical Therapy program, completing the program or securing licensure after graduation.

The University of Evansville reserves the right to exercise judgment in the selection process for the Doctor of Physical Therapy program. All decisions are final. The University of Evansville operates under a non-discriminatory policy with regard to race, color, age, religion, disability, sex and national origin.

Please see the following pages for application submission directions, interview dates, financial aid information for transfer/second degree seeking students, and the Essential Functions.

  1. Instructions for University of Evansville Students-Applicants who will complete a bachelor’s degree at the University of Evansville
Assessment of your application will not begin until all of the followingdocuments are received.All required application materials must be received or postmarked by October 15, 2014.
  1. Doctor of Physical Therapy (DPT) application
  2. Essay
  3. Recommendation forms (2); one from a college professor and one from a physical therapist. The completed form should be returned to you in a sealed envelope and signed across the seal by the person making the recommendation.
  4. Transcripts from all universities attended
Mail or deliver your application materials to:
Sherri Chambliss, Director of Admission and Advising
University of Evansville
Department of Physical Therapy
Graves Hall, room 207
1800 Lincoln Ave.
Evansville, IN 47722
Application materials may also be submitted electronically to: . Electronically submitted recommendations must be submitted by the individuals completing the forms, not the applicant.
Interviews for UE students will be conducted the week of January 19, 2015. Applicants will be notified by mail of their interview status in early December.
  1. Instructions for Transfer/Second Degree Seeking Students-Applicants who have or will complete a bachelor’s degree at aninstitution other than the University of Evansville
Assessment of your application will not begin until all of the following documents are received.All of the application materials must be received or postmarked by October 15, 2014.
  1. DPT program application
  2. DPT essay
  3. Recommendation forms (2); one from a college professor and one from a physical therapist. The completed form should be returned to you in a sealed envelope and signed across the seal by the person making the recommendation.
  4. Official college transcripts from all universities attended
Forward materials to:
University of Evansville
Office of Admissions
1800 Lincoln Ave.
Evansville, IN 47722
Application materials may be submitted electronically to: .
Electronically submitted recommendations must be submitted by the individuals completing the forms, not the applicant.
Interviews for Transfer/Second Degree Seeking Students will be conducted on Monday, January 19, 2015. Applicants will be notified by mail of their interview status in early December.
Financial Assistance for Second Degree Seeking Students
If selected for admission into the DPT program, students will be considered for a UE Academic Scholarship currently worth $10,000 per year when they enroll in the program. Students with a bachelor’s degree may borrow at the graduate level in the Federal Direct Stafford Loan and Grad PLUS Loan programs. This financial aid information also applies to students who earned a BS degree from UE but did not immediately continue in the DPT program.
For more information, call the Office of Financial Aid at 812-488-2364 or 800-488-8634. To apply for aid, students should complete the Free Application for Federal Student Assistance (FAFSA).

ESSENTIAL FUNCTIONS (Applicant to retain this portion of the application)

The Doctor of Physical Therapy Program at the University of Evansville is a complex and intensive course of study. It places specific demands on students that closely resemble the physical and intellectual challenges graduates of the program will encounter as practicing physical therapists. The program has been designed to prepare students to enter the profession of physical therapy as generalists with the ability, knowledge, and skills necessary to successfully perform all of the essential functions expected of entry-level physical therapists. Students are to familiarize themselves with these essential functions and their associated technical standards and determine whether or not they are able to perform the specified tasks.

In accordance with applicable state and federal laws regarding people who have disabilities and our program’s philosophy, we are committed to making reasonable accommodations for students who have disabilities to enable them to successfully perform the essential functions as delineated below. In the event that a student determines he or she cannot meet an essential function due to a disability, either upon admission to the program or at any point thereafter, it is the responsibility of the student to notify the Chair of the Department of Physical Therapy and the Office of Disability Services of that determination and to request a reasonable accommodation. A reasonable accommodation is a strategy, agreed upon by the student and the University, which enables the student to meet a technical standard. The faculty and student will work together, within the context of the agreed upon strategy, to provide the student with the opportunity to meet the technical standard. The presence of a disability will not exempt students from completing required tasks and a reasonable accommodation will not guarantee that students will be successful in meeting the requirements of any one course. Should a student be unable to meet a technical standard or course requirement after a reasonable accommodation has been made, the offer of admission or status in the program will be withdrawn.

The essential functions are:

  1. Affective/behavioral skills
  2. Cognitive skills
  3. Communication skills
  4. Observation skills
  5. Physical and emotional health
  6. Psychomotor skills

To accomplish the essential functions of the role of the physical therapist, the student must be able to meet the following technical standards:

  1. Affective/behavioral skills – use of social and professional skills to demonstrate
  2. Appreciation and respect for individual, social, and cultural differences in fellow students, professional colleagues, patients, and caregivers.
  3. Appreciation that his or her values, attitudes, beliefs, emotions, and experiences affect his or her perceptions and relationships with others.
  4. Appropriate behaviors and attitudes to protect the safety and well-being of patients, self and classmates.
  5. Ability to appropriately handle situations which may be physically, emotionally or intellectually stressful including situations which must be handled swiftly and calmly.
  6. Ability to adjust to changing situations and uncertainty in an academic or clinical environment.
  7. Possession of attributes of accountability, altruism, compassion and caring, excellence, integrity, professional duty, social responsibility, flexibility, empathy and motivation.
  8. Ability to accept constructive feedback and modify behaviors as necessary.
  9. Ability to maintain mature, sensitive, and effective relationships with patients, students, faculty, staff and other professionals in academic and clinical environments.
  10. Ability to reason morally and practice physical therapy in an ethical manner.
  11. Willingness to learn and abide by professional standards of practice.
  12. Ability to be self-reflective.
  13. Ability to be assertive and take initiative as appropriate.
  14. Ability to delegate or direct others and function effectively as part of a health care team.
  1. Cognitive skills – possession of sufficient intellectual-conceptual ability that includes the capacity to measure, calculate, reason, analyze, integrate and synthesize information in order to make decisions. Includes demonstration of the ability to
  2. Comprehend, integrate and synthesize a large body of knowledge in a short period of time.
  3. Utilize knowledge of natural, clinical, and social sciences to develop appropriate interventions in a clinical setting.
  4. Gather appropriate information during patient/client examinations and throughout patient/client management in order to make clinical decisions.
  5. Appraise information and determine appropriate tests and measures during the patient/client examination.
  6. Evaluate the information gleaned from the patient/client examination including patient history and any available medical/surgical and radiologic information to formulate diagnoses, prognoses, and plans of care.
  7. Acknowledge limitations of knowledge and/or performance in order to provide safe, effective patient/client care including the necessity of referring the patient/client to other health care professionals.
  8. Prescribe therapeutic home programs as indicated by the results of the examination utilizing a variety of instructional methods for patients/clients and/or family members.
  9. Reflect on performance to accurately self-assess strengths and weaknesses.
  10. Develop a plan to address areas of weakness.
  1. Communication skills- use of verbal (oral and written) and nonverbal abilities to
  2. Express own ideas and feelings clearly.
  3. Demonstrate willingness and ability to give and receive feedback.
  4. Listen actively in order to receive and interpret oral communication.
  5. Communicate effectively and sensitively in English with other students, faculty, patients, patients’ families, other professionals.
  6. Demonstrate interpersonal skills as needed for productive classroom discussion, respectful interaction with classmates and faculty, and development of appropriate patient/therapist relationships.
  7. Communicate clearly and audibly during interactions with classmates, professors, patients and members of the health care team.
  8. Elicit a thorough history from patients/caregivers.
  9. Communicate complex findings in appropriate terms to patients/caregivers and other members of the health care team.
  10. Receive, write and interpret written communication in both clinical and academic settings.
  11. Read and record observations and plans legibly, efficiently, and accurately in documents such as the patient’s record, both handwritten and electronic.
  12. Complete written assignments.
  13. Establish rapport with client, caregivers, and colleagues.
  14. Observe patients for the purpose of eliciting information, accurately describing changes in facial expression, mood, posture and other nonverbal communication.
  15. Use therapeutic communication such as attending, clarifying, coaching, facilitating and touching.
  1. Observation skills – functional use of vision, hearing, and other sensory modes to
  2. Observe audiovisual presentations, written materials, laboratory demonstrations and procedures.
  3. Effectively perform auscultation/auditory evaluation inclusive of, but not limited to, lung, heart, apical pulse, blood pressure, and joint and prosthetic noises.
  4. Appreciate environmental cues such as phones, paging systems, and verbal communication in a setting with competing ambient noise.
  5. Appropriately take a patient’s/client’s history.
  6. Accurately observe a patient’s/client’s activity and behavior during examinations and interventions.
  7. Observe changes in patient/client status which may require modification of activity or intervention such as: color of skin, breathing regularity, heart rate, skin temperature, muscle tone, and facial expressions.
  8. Accurately monitor dials, displays, and equipment used in treatment of patients including exercise equipment and electrical modalities.
  9. Appreciate tactile feedback related to safe and accurate application of procedures such as palpation, manual muscle testing, and joint mobilization.
  10. Read information from diagnostic tests, equipment, and patient charts such as EKG and radiographs.
  1. Physical and emotional health – excellent physical and emotional health and maintenance of personal hygiene and appearance as demonstrated by the ability to
  2. Perform the skills mentioned in the other sections of this document.
  3. Avoid jeopardizing the health and safety of others with whom one interacts.
  4. Avoid offending others with whom one interacts.
  5. Develop rapport with patients/clients, caregivers, classmates, faculty and other health care professionals.
  6. Respond appropriately to stressful situations in the classroom and clinic.
  1. Psychomotor skills – gross and fine motor skills reflective of the physical capacities required to meet the responsibilities of a physical therapy student in a wide variety of clinical settings. Student should demonstrate the ability to
  2. Assume and maintain a variety of positions, including but not limited to sitting and standing, squatting, kneeling, reaching, walking, stair climbing, and movement of the trunk and neck in all directions.
  3. Perform manual material handling and manipulation of objects of various sizes and weights including lifting and transferring patients/clients, guarding patients/clients during gait training on level and uneven surfaces/ramps/stairs, pushing and pulling to provide resistance, and assisting in maneuvering patients/clients.
  4. Safely lift up to 50 lbs. independently
  5. Safely lift up to 200 lbs. with assistance
  6. Safely push and pull up to 200 lbs. occasionally.
  7. Utilize strong bilateral grasp during joint mobilization/manipulation and manually resisted exercise.
  8. Utilize bilateral fine motor control to manipulate testing instruments/equipment/writing instruments/computers.
  9. Manually palpate various body structures during examination and intervention procedures.
  10. Balance self and provide support and balance to patients/clients on a variety of surfaces.
  11. Perform a variety of endurance activities for up to 8-12 hours with occasional rest breaks. These include the ability to:
  12. Sit for two to 10 hours daily, stand for one to two hours daily, and walk or travel for two hours daily
  13. Frequently lift 10 lbs. and occasionally lift weights between one and 50 lbs.
  14. Occasionally carry up to 25 lbs. while walking up to 50 ft.
  15. Frequently exert up to 75 lbs. of push/pull forces for up to 50 ft, and occasionally exert 200 lbs. for this distance.
  16. Frequently turn, bend, stoop and squat.
  17. Occasionally crawl, reach above shoulder level and kneel.
  18. Frequently change position and location at speeds that permit safe handling of patients/clients.
  19. Frequently stand and walk while providing support to a patient/client with a disability.
  20. Continuously use hands repetitively with a firm grasp and manual dexterity skills.
  21. Frequently coordinate verbal and manual activities with gross motor activities.
  22. Respond quickly to emergency situations by lifting/pushing/pulling patients/clients and applying force to perform CPR and assist with transporting patients/clients.