Physical Therapist Or Physical Therapist Assistant General Response Form

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Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
(517) 373-8068 ● Fax (517) 335-2044
PHYSICAL THERAPIST OR PHYSICAL THERAPIST ASSISTANT
GENERAL RESPONSE FORM
Authority: 1978 PA 368, as amended
An Evaluative Component for Professional Development Requirement (PDR) Credits earned under Activity Code 3 and 4.
Name of Physical Therapist (PT) or Physical Therapist Assistant (PTA):
License Number:
Street Address:
Apt/Bldg:
City:
State:
Zip Code:
Email Address:
Daytime Phone Number:
Pursuant to Rule 338.7163 of the Administrative Rules, Activity Code 3, PDR credit may be awarded for independent
reading of article(s) related to the practice of physical therapy in a professional or scientific journal for a maximum of 6 PDR
credits; Activity Code 4 indicates that PDR credits may be awarded for viewing or listening to media related to the practice
of physical therapy for a maximum of 6 PDR credits. If audited you must successfully complete an evaluation provided
with each article/media and/or a General Response Form.
PLEASE PROVIDE INFORMATION BELOW REGARDING EACH ACTIVITY.
Please note that you are able to earn one PDR credit for each article read under Activity Code 3. In addition, you are able to earn
one PDR credit for each hour spent viewing or listening to media under Activity Code 4. These activities do not include those that
are approved for PDR credit under Activity Code 1.
ACTIVITY #1
Name & Date of Article or Media Publication:
Publisher:
Type of activity:  article/reading
 audio/visual media
Date of activity & amount of time spent:
Please provide a brief summary of the article/media:
 Yes
 No
Did this article/media meet your expectations?
 Yes
 No
Would you recommend this article to other physical therapists or physical therapist assistants?
How will the information presented assist you in performing the duties as a physical therapist or physical therapist assistant?
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political
.
beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency

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