Mercer PA Program Patient Care Hours Update

Thank you for applying to our Physician Assistant Program. Please use this form to provide an update of your patient care experiences completed since you have submitted your CASPA application. PLEASE USE THIS FORM TO REPORT NEW HOURS ONLY... do not give a total of previous hour coupled with new hours. If you have any questions, please contact the Admissions office at 678-547-6391 or email us at paprogram@mercer.edu.

Question Title

* 1. Contact Information

Name:

CASPA ID:

Email Address:

Phone Number:

Question Title

* 2. Patient Care Experience #1

Title:

Employer:

Supervisor:

City:

State:

Phone Number:

Start Date of NEW Hours:

End Date of NEW Hours:

Number of NEW Weeks:

Number of NEW Hours per Week:

Total of NEW Hours:

Question Title

* 3. Duties for Patient Care Experience #1 - Please indicate all duties where you were directly responsible for a patient's care:

Question Title

* 4. Patient Care Experience #2

Title:

Employer:

Supervisor:

City:

State:

Phone Number:

Start Date of NEW Hours:

End Date of NEW Hours:

Number of NEW Weeks:

Number of NEW Hours per Week:

Total of NEW Hours:

Question Title

* 5. Duties for Patient Care Experience #2 - Please indicate all duties where you were directly responsible for a patient's care:

Question Title

* 6. Patient Care Experience #3

Title:

Employer:

Supervisor:

City:

State:

Phone Number:

Start Date of NEW Hours:

End Date of NEW Hours:

Number of NEW Weeks:

Number of NEW Hours per Week:

Total of NEW Hours:

Question Title

* 7. Duties for Patient Care Experience #3 - Please indicate all duties where you were directly responsible for a patient's care:

Question Title

* 8. Please include any new shadowing / non-direct patient care experiences that you would like to include on your application. Please note, these experiences will not be included in our calculation of your total hours of direct patient experiences.