CLINICAL MENTOR RECOMMENDATION
Application for Advanced Proficiency Pathways for the PTA
The following applicant,
, is applying for Advanced Proficiency Pathway in
Please answer the following questions and complete the recommendation rubric.
physical therapy.
How long have your worked with the applicant?
The applicant …
Demonstrates at least entry-level knowledge in patient/client
interventions and related data collection.
Demonstrates at least entry-level skill competence in
patient/client interventions and related data collection.
Demonstrates willingness to increase knowledge and skill
performance in the selected Advanced Proficiency Pathway
content area.
Demonstrates ability to develop additional knowledge and
skill in the selected Advanced Proficiency Pathway content
area.
Assumes responsibility for educational and career
development.
Acquires knowledge in a self-directed and focused manner.
Demonstrates values through behaviors that are consistent
with the Values-based Behaviors for the PTA.
Actively collaborates with the physical therapist, patient/client,
and other members of the health care team.
Demonstrates potential for growth and development in the
areas of advocacy and leadership.
Has a history of completing projects and assignments without
prompting.
Additional Comments:
Continue to page 2.
4.1.14
Strongly
Agree
Agree
Disagree
Strongly
Disagree
Briefly describe your qualifications in the selected Advanced Proficiency Pathway content area.
Certifications
(eg, ABPTS certification,
Advanced Proficiency in
Geriatric Physical Therapy,
CLT)
Related Work Experience
(include dates)

Related Continuing
Education
(past 5 years only)

Related Presentations


Advanced Proficiency Pathway Partnering Agreement
I understand that the applicant must meet all of the requirements of the Advanced Proficiency Pathway to
earn his/her Certificate of Advanced Proficiency in ________________ Physical Therapy, including:
1. 60 contact hours of selected continuing education courses that meet the defined
guidelines and content of the APP, including:
 APTA ‘core’ courses
 Selected content courses or equivalent APTA approved courses
2. Mentored clinical experiences* with the supervising physical therapist and clinical mentor
3. 2000 clinical hours of work experience in the content area
4. Successful completion of all competency-based assessments, including
 Knowledge assessment via course examinations; and
 Skill assessment via skill checks by the clinical mentor
By signing and submitting this reference, I am agreeing to assist the applicant in completing the
Advanced Proficiency Pathway. I have the requisite knowledge and skill in the selected Advanced
Proficiency Pathway to provide clinical instruction, mentoring, and assessment of skill mastery. I will also
provide the applicant with professional and/or personal support to the applicant, as able, and will
demonstrate professional behaviors. I will promote enhanced PT-PTA collaboration, including
communication and documentation. I will assure that the applicant obtains proficiency in all of the items
listed on the skill rubric; and provide documentation at the conclusion of the program of the same.
Signature (electronic signatures are acceptable):
Facility:
Preferred contact phone: (
)
Preferred contact e-mail address:
Please e-mail your completed reference and agreement and your current resume to PTA@apta.org
before the due date. Thank you.
4.1.14