Program Director/Program Coordinator Information Form
Please print all information.
Full Name and Credentials:
Title:
Program Director
Phone Number:
Name of Residency/Fellowship Program:
Program Coordinator
Email Address:
Number of hours per week dedicated to the residency/fellowship program:
Has there been a change in the program director’s job description from what was previously filed?
Yes
No
If yes, please provide the program director’s job description that includes ensuring the program’s
compliance with the provisions of the current version of the ABPTRFE Evaluative Criteria and Rules of
Practice and Procedure.
For program directors of developing and candidate programs only:
Have you taken the Residency/Fellowship 101 Course?
Yes
No
If yes, please attach a copy of the course certificate to this form.
If no, have you previously been a program director of an APTA-accredited residency or fellowship
program?
Yes
No
If yes, please provide the name of the program and the dates you were program director:
Name of Program:
Dates: From
To
For programs enrolled in RF-PTCAS:
Please contact Kate Owen, Senior Customer Solutions Manager at kowen@liaison-intl.com to inform her
of a change in program director.
Submission of Form:
A copy of the individual’s curriculum vitae MUST be included with this form.
If submitting this form as part of an accreditation application, please embed the document and CV in the
program’s application.
If submitting this form as part of a substantive change to a program that is currently in candidate status or
accredited, please convert a completed substantive change form, this form, and the curriculum vitae to
one .pdf file and email it to resfel@apta.org.