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Supporting Supervised Clinical Practice Form

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Academic year: 2022

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1243 Islington Avenue, Suite 501 Toronto, Ontario M8X 1Y9 P : 416 234 8800 | F : 416 234 8820 www.alliancept.org

180401

Supporting Supervised Clinical Practice Form

Please complete the following chart with the locations, dates, area of practice and hours the student has completed during each clinical placement as part of their degree requirements. This information must support the information provided on Form D – Document Request Form. Alternative supplement information is required for students from Bangladesh, India, Pakistan and The Philippines; please review Form D for what we require from your institution.

Full Name of Student (Print): ____________________________________________________________ has completed the following supervised clinical practice.

The institution must send this information directly to the CAPR office in a stamped and sealed envelope that lists the institution as the sender. We will not accept this form if the student or any relative or friend of the applicant completes it or sends it to us.

Name of Official (Print) Title/Position

Date Signature

Name of Institution

Locations Dates

Start to End

Areas of Practice

(e.g. musculoskeletal, neurological, cardiorespiratory and others)

Hours

Références

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