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Form 08-4091d - Preceptorship Statement For Internship Of Foreign-Trained Physical Therapist Page 2

9. Approximate number of patients seen per day or week for preceptor

;

for department

10. Provide brief descriptions of other programs, services, activities at facility (e.g., rounds, staffings, continuing

education, etc.).

ACTIVITY

FREQUENCY

11. Possibilities for experience at other agencies/facilities:

12. Describe how direct on-site supervision by preceptor shall be provided:

I, the undersigned, agree to act as preceptor for

for a period of 6 to 12 months. At the end of a minimum of 6 months, I will provide a full report to the State Physical

Therapy and Occupational Therapy Board describing performance during the internship. I understand the foreign-

trained therapist applicant must be under my continuous, direct supervision for the length of the internship. I attest

that I will be working full-time and I assume responsibility for the intern’s experience and the safety and welfare of

the patient.

Signed:

Date:

Please return completed form to:

Department of Community and

Economic Development

Division of Occupational Licensing

P.O. Box 110806

Juneau, AK 99811-0806

08-4091d (Rev. 8/00)

Form 08-4091d - Preceptorship Statement For Internship Of Foreign-Trained Physical Therapist Page 2