Misericordia University

USE ONE FORM FOR EACH DIRECT PATIENT CARE EXPERIENCE/EMPLOYER

College of Health Science and Education

Department of Physician Assistant Studies

DOCUMENTATION of DIRECT PATIENT CARE EXPERIENCE FORM

Applicant: Please provide evidence of at least *250 hours of direct patient care experience, performed under the supervision of a licensed health care professional. *The minimum of 500 hours of direct patient care experience required at the time of application submission will be reduced to 250 hours of direct patient care experience to accommodate for situations in which an applicant may not have been able to complete these hours due to clinic closures or removal of students from those settings. Please note – This requirement will be modified for the 2019-2020 and 2020-2021 application cycles only.

Acceptable experiences include but are not limited to: Pharmacist; Chiropractor; Corpsman/ Medic /Independent Duty Corpsman; Forensic Pathologist; International Medical Graduate with US Healthcare System Experience; Registered Nurse; Certified Registered Nurse Practitioner; Osteopathic Physician; Medical Doctor; Paramedic AAS; Physical Therapist; Podiatrist; Anesthesia Tech; Cardiovascular Tech; Athletic Trainer; Emergency Room Tech; Surgical Tech; Massage Therapist; Occupational Therapist; Certified Occupational Therapist Assistant; Physical Therapist; Physical Therapy Assistant; Speech-Language Pathologist; Emergency Medicine Tech; Licensed Practical Nurse; Medical Assistant; Phlebotomist; Certified Nursing Assistant; Physical Therapy or Occupational Therapy Assistant; Pharmacy Tech; Personal Trainer; Medical Scribe. (Note: “On call” and “standby” time does not qualify).

Falsification of any part of this document, or lack of any signature, will result in the removal of the applicant for admission consideration or, if previously admitted, immediate dismissal from the program.

APPLICANT INFORMATION

Applicant First Name:

Applicant Last Name:

Email:

Phone:

CASPA ID:

Address

City

State

Zip Code

DIRECT CARE EXPERIENCE INFORMATION

Name of where the Direct Patient Care Experience occurred:

Address

City

State

Zip Code

Position title:

Total Hours Claimed:

Dates of Experience:

Describe your direct patient care experience. Include type of setting (ie: nursing home, emergency room, ambulance,etc.), services and tasks performed. (limit 1,000 characters) (Maximum characters: 1000)
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