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Form 08-4091d - Preceptorship Statement For Internship Of Foreign-Trained Physical Therapist

Department of Community and Economic Development

Division of Occupational Licensing

State Physical Therapy and Occupational Therapy Board

P.O. Box 110806

Juneau, Alaska 99811-0806

Telephone: (907) 465-2580

E-mail: license@dced.state.ak.us

PRECEPTORSHIP STATEMENT FOR INTERNSHIP

OF FOREIGN-TRAINED PHYSICAL THERAPIST

This internship must be reviewed and approved by the board before the internship can take place. DO NOT

BEGIN INTERNSHIP UNTIL APPROVED BY THE BOARD.

1. Name of Facility:

Type of Facility:

2. Mailing Address:

City:

State:

ZIP Code:

Telephone:

3. Date internship will start:

Date facility would like board to review preceptor's report of performance:

4. Name of Supervisor:

Present Position:

Years Experience:

5. Professional staff in department and number of hours worked per week:

(Must have at least two full-time licensed physical therapists on staff)

6. Other staff in department:

7. Describe the facility case load by giving the approximate number of cases for the following categories:

(Preceptor is not expected to treat all types of patients.)

A. Modalities

C. Chronic – orthopedic

E. Sterile technique

– neurologic

(wounds, burns, frostbite, etc.)

B. Acute – orthopedic

D. Pediatric – orthopedic

F. Other (list)

– neurologic

8. Describe the experience expected for the foreign-trained therapist (therapist is not expected necessarily to

treat all types of patients, but must treat a variety of patients). Experience should be in any of the cases

directed in #7 above.

08-4091d (Rev. 8/00)

Form 08-4091d - Preceptorship Statement For Internship Of Foreign-Trained Physical Therapist