Clinical Data Form

Please complete all sections of this data form
Name: 


  1. Student Name


  1. PTA199 Site Name


  1. Site Address


  1. Site Phone Number


  1. CI Name


  1. CI Cell #


  1. CI Email Address


  1. Schedule Days (Mon, Tues, Wed, Thurs, Fri, Sat, Sun)


  1. Schedule Hours (7-4, 8-5, 9-6, etc.).


  1. Clinical Dates


  1. CI using on-line or paper CPI?


  1. Clinical Rotation (i.e. PTA199, PTA259, PTA289)





Dr. Mills
PTA Program Director
Carrington College Las Vegas
Las Vegas, NV