Get Apta Participant Dossier Form 2012.doc - Jscc

Filling out the APTA Participant Dossier Form is an essential step for participants in the clinical instructor education and credentialing program. This guide provides a clear and structured approach to completing the form online, ensuring accuracy and completeness.

Follow the steps to complete the form accurately and efficiently.

1. Click 'Get Form' button to obtain the form and open it in your preferred document editor.
2. In the 'Participant Contact Information' section, fill in your name, date of birth, mailing address, city, state, zip, home phone, work phone, and email address. Ensure that all information is current and accurate.
3. Proceed to the 'Participant Education/Professional Information' section. Enter your type of entry-level degree, date of graduation from an accredited program, number of years as a clinician, years supervising students, and highest degree earned.
4. Complete the professional designation and APTA membership number sections. Attach a copy of your membership card if required.
5. Indicate whether you require any special accommodations by selecting 'Yes' or 'No.' If 'Yes,' specify the accommodations needed.
6. List the state(s) where you are licensed/registered/certified and provide a copy of your license for the state in which you work.
7. In the 'Employment History' section, start with your most recent employer. Document the employer's name, city/state, job description, and the dates of employment.
8. The next section requires your direct supervisor to complete the evaluation of your clinical competence and skills. Ensure that they are aware they need to evaluate you on multiple criteria.
9. Answer the questions regarding permission for APTA to release your contact information for research and marketing purposes by selecting 'Yes' or 'No.'
10. Include your electronic signature and the signature and title of your direct supervisor. Lastly, date the form.
11. Once you have completed all sections, review your information for any errors or omissions before saving your changes. You can then download, print, or share the form as needed.

Complete your documentation online today to ensure your participation in the program.