Physical Therapist Or Physical Therapist Assistant General Response Form Page 2

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Page 2 of 3 (11/15)
NAME OF PT OR PTA ___________________________________
LICENSE NO __________________________
*YOU MAY MAKE ADDITIONAL COPIES OF THIS PAGE AS NEEDED.*
ACTIVITY #_____ of _____
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?
ACTIVITY #_____ of _____
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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