Post on 29-Jul-2018
CLINICAL SITE INFORMATION FORM
Initial Date 12/04/06
Revision Date 12/28/09 Person Completing CSIF Kerri Yacovelli, MSPT
E-mail address of person completing CSIF
kyacovelli@selectmedicalcorp.com
Name of Clinical Center NovaCare Rehabilitation
Street Address 1 Trenton Avenue, Store 8-A
City Morrisville State
PA Zip 19067
Facility Phone 215-295-4538 Ext.
PT Department Phone 215-295-4538 Ext.
PT Department Fax 215-295-3895
PT Department E-mail kyacovelli@hq.novacare.com
Clinical Center Web Address
NovaCare.com
Director of Physical Therapy
Todd Brutto, PT
Director of Physical Therapy E-mail TBrutto@selectmedicalcorp.com
Center Coordinator of Clinical Education (CCCE) / Contact Person
Kerri Yacovelli, MSPT
CCCE / Contact Person Phone 215-295-4538
CCCE / Contact Person E-mail kyacovelli@selectmedicalcorp.com
APTA Credentialed Clinical Instructors (CI) (List name and credentials)
Kerri Yacovelli, MSPT (Morrisville) Eric Czerwinski, MSPT (Feasterville) Joslyn Gower, DPT (Bristol) Franklin Antosh, MPT (Scranton)
Other Credentialed CIs (Select Medical Corporation CI Course in SERC- internal training)
Jessica Sliker, PTA (Morrisville) Michelle Friedman, DPT (Neshaminy) Jessica Barrientos, DPT (Juniata Park) Christopher Lenihan, PT (Juniata Park)
Johanna Afanador, DPT (Juniata Park) Mark Human, MSPT (Northeast) Jamie Howard, DPT (Northeast) Ali El-Kerdi, DPT (Northeast) Forina Gallagher, PTA (Northeast) Mariann Harris, PTA (Northeast) Dave Miller, PT (Rockledge) Edwin Crane, DPT (Bristol) Caroline Opperman, PTA (Bristol) Walter Scarborough, PT (Langhorne) Bernadette Mellon, PTA (Langhorne)
Indicate which of the following are required by your facility prior to the clinical education experience:
Proof of student health clearance Criminal background check First Aid and CPR HIPAA education OSHA education
Information About Multi-Center Facilities
Name of Clinical Site NovaCare Rehabilitation- Morrisville
Street Address 1 E Trenton Ave Store 8A
City Morrisville State PA Zip 19067
Facility Phone 215-295-4538 Ext.
PT Department Phone 215-205-4538 Ext.
Fax Number (215) 295-3895 Facility E-mail
Director of Physical Therapy
Todd Brutto, PT
E-mail TBrutto@selectmedicalcorp.com
CCCE
Kerri Yacovelli, MSPT E-mail kyacovelli@selectmedicalcorp.com
Name of Clinical Site NovaCare Rehabilitation- Neshaminy
Street Address 11596 Roosevelt Blvd
City Philadelphia State PA Zip 19116
Facility Phone 215-677-8200 Ext.
PT Department Phone 215-677-8200 Ext.
Fax Number 215-969-2681 Facility E-mail
Director of Physical Therapy
Michelle Friedman, DPT E-mail MWFriedman@selectmedicalcorp.com
CCCE
Kerri Yacovelli, MSPT E-mail kyacovelli@selectmedicalcorp.com
Name of Clinical Site NovaCare Rehabilitation-Juniata Park
Street Address 1107-11 East Erie Avenue
City Philadelphia State PA Zip 19124
Facility Phone 215-743-3699 Ext.
PT Department Phone 215-743-3699 Ext.
Fax Number 215-743-5045 Facility E-mail
Director of Physical Therapy
Jessica Barrientos, DPT
E-mail jbarrientos@hq.novacare.com
CCCE
Kerri Yacovelli, MSPT E-mail kyacovelli@selectmedicalcorp.com
Name of Clinical Site NovaCare Rehabilitation-Feasterville
Street Address 1040 Mill Creek Drive
City Feasterville State PA Zip 19053
Facility Phone 215-357-2363 Ext.
PT Department Phone 215-357-2363 Ext.
Fax Number 215-357-2427 Facility E-mail
Director of Physical Therapy
Eric Czerwinski, MSPT
E-mail Eczerwinski@hq.novacare.com
CCCE
Kerri Yacovelli, MSPT E-mail kyacovelli@selectmedicalcorp.com
Name of Clinical Site NovaCare Rehabilitation-Rockledge
Street Address 412 Huntingdon Pike
City Rockledge State PA
19046
Facility Phone 215-663-8710 Ext.
PT Department Phone 215-663-8710 Ext.
Fax Number 215-663-8717 Facility E-mail
Director of Physical Therapy
Dave Miller, PT
E-mail dmiller@hq.novacare.com
CCCE
Kerri Yacovelli, MSPT E-mail kyacovelli@selectmedicalcorp.com
Name of Clinical Site NovaCare Rehabilitation- Northeast
Street Address 6595 B East Roosevelt Boulevard
City Philadelphia State PA
Zip
19149
Facility Phone 215-743-2332 Ext.
PT Department Phone 215-743-2332 Ext.
Fax Number 215-743-2330 Facility E-mail
Director of Physical Therapy
Mark Human, MSPT
E-mail MHuman@selectmedicalcorp.com
CCCE
Kerri Yacovelli, MSPT E-mail kyacovelli@selectmedicalcorp.com
Name of Clinical Site NovaCare Rehabilitation- Bristol
Street Address 100 Green Lane, Suite 1
City Bristol State PA
Zip
19007
Facility Phone 215-826-0166 Ext.
PT Department Phone 215-826-0166 Ext.
Fax Number 215-215-826-0285 Facility E-mail
Director of Physical Therapy
Edwin Crane, DPT
E-mail ecrane@hq.novacare.com
CCCE
Kerri Yacovelli, MSPT E-mail kyacovelli@selectmedicalcorp.com
Name of Clinical Site Worknet- Langhorne, managed by NovaCare Rehabilitation
Street Address 400 N Oxford Valley Road
City Langhorne State PA
Zip
19047
Facility Phone 215- 943-9000 Ext.
PT Department Phone 215-943-9000 Ext.
Fax Number 215-949-8532 Facility E-mail
Director of Physical Therapy
Bernadette Mellon
E-mail BMellon@hq.novacare.com
CCCE
Kerri Yacovelli, MSPT E-mail kyacovelli@selectmedicalcorp.com
Name of Clinical Site NovaCare Rehabiliatation/ Cedarbrook
Street Address 3201 Cheltenham Avenue, Cedarbrook Plaza, Suite 207
City Wyncote State PA
Zip
19095
Facility Phone 215- 517-7551 Ext.
PT Department Phone 215-517-7551 Ext.
Fax Number 215-517-7549 Facility E-mail
Director of Physical Therapy
Frank Serino
E-mail FSerino@selectmedicalcorp.com
CCCE Kerri Yacovelli, MSPT E-mail kyacovelli@selectmedicalcorp.com
Name of Clinical Site NovaCare Rehabilitation/ Scranton
Street Address 555 Lachawanna Avenue
City Scranton State PA
Zip
18503
Facility Phone 570- 344-0705 Ext.
PT Department Phone 570-344-0705 Ext.
Fax Number 570-344-0720 Facility E-mail
Director of Physical Therapy
Frank Serino, MSPT
E-mail FSerino@selectmedicalcorp.com
CCCE
Kerri Yacovelli, MSPT E-mail kyacovelli@selectmedicalcorp.com
Name of Clinical Site NovaCare Rehabilitation/ Plains
Street Address 40667 North River Street
City Plains State PA
Zip
18705
Facility Phone 570-825-7676 Ext.
PT Department Phone 570-825-7676 Ext.
Fax Number 570-825-3424 Facility E-mail
Director of Physical Therapy
Frank Serino, MSPT
E-mail FSerino@selectmedicalcorp.com
CCCE
Kerri Yacovelli, MSPT E-mail kyacovelli@selectmedicalcorp.com
Clinical Site Accreditation/Ownership Yes No Date of Last
Accreditation/Certification X Is your clinical site certified/ accredited? If no, go to #3.
If yes, has your clinical site been certified/accredited by:
JCAHO
CARF
Government Agency (eg, CORF, PTIP, rehab agency, state, etc.)
Other
Which of the following best describes the ownership category for your clinical site? (check all that apply)
Corporate/Privately Owned
Clinical Site Primary Classification To complete this section, please: A. Place the number 1 (1) beside the category that best describes how your facility functions the majority (> 50%) of the time. Click on the drop down box to the left
to select the number 1. B. Next, if appropriate, check (?) up to four additional categories that describe the other clinical centers associated with your facility.
Acute Care/Inpatient Hospital
Facility X Industrial/Occupational
Health Facility School/Preschool Program
1 Ambulatory Care/Outpatient Multiple Level Medical
Center X Wellness/Prevention/Fitness
Program ECF/Nursing Home/SNF Private Practice Other: Specify
Federal/State/County Health X Rehabilitation/Sub-acute
Rehabilitation
Clinical Site Location
Information About the Clinical Teaching Faculty
ABBREVIATED RESUME FOR CENTER COORDINATORS OF CLINICAL EDUCATION
NAME: Kerri Yacovelli, MSPT
Length of time as the CCCE: 2 years
DATE: December 29, 2009
Length of time as a CI: 9 years
PRESENT POSITION: Staff Physical Therapist, CCCE, CI
Mark (X) all that apply: PT (X)
Length of time in clinical practice: 10 years
LICENSURE: (State/Numbers) PA-012699-L, DAPT-001866
APTA Credentialed CI Yes
Other CI Credentialing
Eligible for Licensure: Certified Clinical Specialist:
Area of Clinical Specialization:
Other credentials:
INSTITUTION
PERIOD OF STUDY
MAJOR DEGREE
FROM TO
College Misericordia 9/94 5/99 Entry level PT MSPT
. SUMMARY OF PRIMARY EMPLOYMENT
PERIOD OF EMPLOYMENT
Position
FROM TO
NovaCare Rehabilitation Staff PT, CCCE,CI 11/09 present
Bucks Physical Therapy Staff PT, CI 01/09 11/09
NovaCare Rehabiliation Staff PT, CCCE, CI 03/02 01/09
The Rehab Place Staff PT 07/99 03/02
CONTINUING PROFESSIONAL PREPARATION RELATED DIRECTLY TO CLINICAL TEACHING RESPONSIBILITIES
Course Provider/Location Date
APTA Credentialing 2008
CLINICAL INSTRUCTOR INFORMATION
Morrisville
L= Licensed, Number E= Eligible T= Temporary
Name followed by credentials (eg, Joe Therapist, DPT, OCS
Jane Assistant, PTA, BS)
PT/PTA Program
from Which CI Graduated
Year of Graduation
Highest Earned Physical Therapy Degree
No. of
Years of Clinical Practice
No. of Years
as a CI
APTA Credentialed Clinical Instructor
L/E/T Number
State of Licensure
Kerri Yacovelli, MSPT College Misericordia
1999 MSPT 10 9 YES PT-012699-L DAPT-001866
PA
Jessica Sliker, PTA, C.Ped. Mercer County Community College
2002 PTA 8 years 6 NO TEI002152
PA
Neshaminy
Name followed by credentials (eg, Joe Therapist, DPT, OCS
Jane Assistant, PTA, BS)
PT/PTA Program
from Which CI Graduated
Year of Graduation
Highest Earned Physical
No. of
Years of Clinical
No. of Years
as a CI
APTA Credentialed Clinical Instructor
L= Licensed, Number E= Eligible T= Temporary
Therapy Degree
Practice
L/E/T Number
State of Licensure
Michelle Friedman, DPT Drexel University 2007 DPT 4 3 NO PT018925 PA
Juniata Park
L= Licensed, Number E= Eligible T= Temporary
Name followed by credentials (eg, Joe Therapist, DPT, OCS
Jane Assistant, PTA, BS)
PT/PTA Program
from Which CI Graduated
Year of Graduation
Highest Earned Physical Therapy Degree
No. of
Years of Clinical Practice
No. of Years
as a CI
APTA Credentialed Clinical Instructor
L/E/T Number
State of Licensure
Jessica Barrientos, DPT Temple University 1999 DPT 10 9 NO PT012989L PA
Christopher Lenihan, PT University of Salford (England)
2003 BA 7 4 NO PT019874 PA
Johanna Afanador, DPT Temple 2008 DPT 2 1 NO PT019624 PA
Feasterville
L= Licensed, Number E= Eligible T= Temporary
Name followed by credentials (eg, Joe Therapist, DPT, OCS
Jane Assistant, PTA, BS)
PT/PTA Program
from Which CI Graduated
Year of Graduation
Highest Earned Physical Therapy Degree
No. of
Years of Clinical Practice
No. of Years
as a CI
APTA Credentialed Clinical Instructor
L/E/T Number
State of Licensure
Eric Czerwinski, MSPT Thomas Jefferson University
2004 MSPT 6 3 YES PT017231 PA
Northeast
L= Licensed, Number E= Eligible T= Temporary
Name followed by credentials (eg, Joe Therapist, DPT, OCS
Jane Assistant, PTA, BS)
PT/PTA Program
from Which CI Graduated
Year of Graduation
Highest Earned Physical Therapy Degree
No. of
Years of Clinical Practice
No. of Years
as a CI
APTA Credentialed Clinical Instructor
L/E/T Number
State of Licensure
Mark Human MSPT Beaver College 1996 MSPT 14 13 NO PT010120 PA
Jamie Howard, DPT Drexel University 2004 DPT 5 0 NO PT017054 PA
Ali El-Kerdi, DPT University of Maryland Eastern Shore
2005 DPT 5 4 NO PT018723 PA
Florina Gallagher, PTA Hahnemann University
1991 PTA 19 13 NO TE1000686 PA
Mariann Smith PTA Harcum College 2001 PTA 9 7 NO TE006617 PA
Rockledge
L= Licensed, Number E= Eligible T= Temporary
Name followed by credentials (eg, Joe Therapist, DPT, OCS
Jane Assistant, PTA, BS)
PT/PTA Program
from Which CI Graduated
Year of Graduation
Highest Earned Physical Therapy Degree
No. of
Years of Clinical Practice
No. of Years
as a CI
APTA Credentialed Clinical Instructor
L/E/T Number
State of Licensure
Dave Miller, PT Temple University St. Josephs University: MS Health Administration
1978 2002
BA 32 7 NO PT 003544-L PA
Bristol
L= Licensed, Number E= Eligible T= Temporary
Name followed by credentials (eg, Joe Therapist, DPT, OCS
Jane Assistant, PTA, BS)
PT/PTA Program
from Which CI Graduated
Year of Graduation
Highest Earned Physical Therapy Degree
No. of
Years of Clinical Practice
No. of Years
as a CI
APTA Credentialed Clinical Instructor
L/E/T Number
State of Licensure
Edwin Crane, DPT, DAC Arcadia University
2005 DPT 6 4 NO PT 017641 PA
Joslyn Gower, DPT Arcadia University
2005 DPT 5 3 YES PT 017509 PA
Caroline Opperman, PTA Harcum College 1997 PTA 13 3 NO TE1000821 PA
Langhorne
L= Licensed, Number E= Eligible T= Temporary
Name followed by credentials (eg, Joe Therapist, DPT, OCS
Jane Assistant, PTA, BS)
PT/PTA Program
from Which CI Graduated
Year of Graduation
Highest Earned Physical Therapy Degree
No. of
Years of Clinical Practice
No. of Years
as a CI
APTA Credentialed Clinical Instructor
L/E/T Number
State of Licensure
Walter Scarborough, PT Arcadia University
1999 MSPT 11 2 NO PT 013152L PA
Bernadette Mellon, PTA Penn State- Hazelton
1998 PTA 12 2 NO TE1001457 PA
Cedarbrook
L= Licensed, Number E= Eligible T= Temporary
Name followed by credentials (eg, Joe Therapist, DPT, OCS
Jane Assistant, PTA, BS)
PT/PTA Program
from Which CI Graduated
Year of Graduation
Highest Earned Physical Therapy Degree
No. of
Years of Clinical Practice
No. of Years
as a CI
APTA Credentialed Clinical Instructor
L/E/T Number
State of Licensure
Tom Cicippio, MPT Temple University
2006 MPT 3 1 YES PT-018352-L PA
Scranton
L= Licensed, Number E= Eligible T= Temporary
Name followed by credentials (eg, Joe Therapist, DPT, OCS
Jane Assistant, PTA, BS)
PT/PTA Program
from Which CI Graduated
Year of Graduation
Highest Earned Physical Therapy Degree
No. of
Years of Clinical Practice
No. of Years
as a CI
APTA Credentialed Clinical Instructor
L/E/T Number
State of Licensure
Franklin Antosh, MPT USP 2007 MPT 2 1 YES PT-018877-L PA
PA
Plains
L= Licensed, Number E= Eligible T= Temporary
Name followed by credentials (eg, Joe Therapist, DPT, OCS
Jane Assistant, PTA, BS)
PT/PTA Program
from Which CI Graduated
Year of Graduation
Highest Earned Physical Therapy Degree
No. of
Years of Clinical Practice
No. of Years
as a CI
APTA Credentialed Clinical Instructor
L/E/T Number
State of Licensure
Josh Hogan, MSPT College Misericordia
1999 MSPT 10 8 Yes PT-012834-L PA
Clinical Instructors What criteria do you use to select clinical instructors? APTA Clinical Instructor Credentialing No criteria Career ladder opportunity Other (not APTA) clinical instructor credentialing Certification/training course X Therapist initiative/volunteer X Clinical competence X Years of experience Delegated in job description X Other (please specify): X Demonstrated strength in clinical
teaching “Clinical Instructor Training: Planning and
Preparing for Students” internal module
How are clinical instructors trained? (Mark (X) all that apply)
X 1:1 individual training (CCCE:CI) Continuing education by consortia
Academic for-credit coursework No training
X APTA Clinical Instructor Education and Credentialing Program
X Other (not APTA) clinical instructor credentialing program
X Clinical center inservices X Professional continuing education (eg, chapter, CEU course)
Continuing education by academic program
X Other (please specify): “Clinical Instructor Training: Planning and Preparing for Students”
internal module
Information About the Physical Therapy Service
Number of Patients/Clients Estimate the average number of patient/client visits per day:
INPATIENT OUTPATIENT Individual PT 16 Individual PT
Student PT varies Student PT Individual PTA 16 Individual PTA Student PTA varies Student PTA PT/PTA Team PT/PTA Team Total patient/client visits per day Total patient/client visits per day
Patient/Client Lifespan and Continuum of Care Indicate the frequency of time typically spent with patients/clients in each of the categories using the key below: 1=(0%) 2=(1-25%) 3=(26-50%) 4=(51-75%) 5=(76-100%) Rating Patient Lifespan Rating Continuum of Care
2 0-12 years 1 Critical care, ICU, acute 2 13-21 years 1 SNF/ECF/sub-acute 4 22-65 years 2 Rehabilitation 3 Over 65 years 4 Ambulatory/outpatient 1 Home health/hospice 4 Wellness/fitness/industry
Patient/Client Diagnoses 1. Indicate the frequency of time typically spent with patients/clients in the primary diagnostic groups (bolded) using the key below:
1 = (0%) 2 = (1-25%) 3 = (26-50%) 4 = (51-75%) 5 = (76-100%)
(1-5) Musculoskeletal
3 Acute injury 3 Muscle disease/dysfunction 2 Amputation 3 Musculoskeletal degenerative disease 3 Arthritis 4 Orthopedic surgery 3 Bone disease/dysfunction Other: (Specify) 3 Connective tissue disease/dysfunction
(1-5) Neuro-muscular
2 Brain injury 2 Peripheral nerve injury 2 Cerebral vascular accident 2 Spinal cord injury 3 Chronic pain 2 Vestibular disorder 2 Congenital/developmental Other: (Specify) 2 Neuromuscular degenerative disease
(1-5) Cardiovascular-pulmonary
2 Cardiac dysfunction/disease 1 Peripheral vascular dysfunction/disease 2 Fitness Other: (Specify) 2 Lymphedema 2 Pulmonary dysfunction/disease
(1-5) Integumentary
1 Burns Other: (Specify) 2 Open wounds 2 Scar formation
(1-5) Other (May cross a number of diagnostic groups)
2 Cognitive impairment 2 Organ transplant 2 General medical conditions 2 Wellness/Prevention 2 General surgery Other: (Specify) 2 Oncologic conditions
Hours of Operation
Facilities with multiple sites with different hours must complete this section for each clinical center. Morrisville
Days of the Week From: (a.m.) To: (p.m.) Comments Monday 8:00 7:00 Tuesday 8:00 7:00 Wednesday 8:00 7:00 Thursday 8:00 7:00 Friday 8:00 4:00 Saturday Sunday
Neshaminy Days of the Week From: (a.m.) To: (p.m.) Comments
Monday 8:00 7:00 Tuesday 8:00 7:00 Wednesday 8:00 5:00 Thursday 8:00 7:00 Friday 8:00 4:00 Saturday Sunday Juniata Park
Days of the Week From: (a.m.) To: (p.m.) Comments Monday 8:00 7:00 Tuesday 8:00 7:00 Wednesday 8:00 7:00 Thursday 8:00 7:00 Friday 8:00 2:00
Saturday Sunday Northeast
Days of the Week From: (a.m.) To: (p.m.) Comments Monday 7:30 7:30 Tuesday 7:30 7:30 Wednesday 7:30 7:30 Thursday 7:30 7:30 Friday 8:00 5:00 Saturday Sunday Rockledge
Days of the Week From: (a.m.) To: (p.m.) Comments Monday 8:00 7:00 Tuesday 9:00 7:00 Wednesday 8:00 1:00 Thursday 9:00 7:00 Friday 8:00 2:00 Saturday Sunday Bristol
Days of the Week From: (a.m.) To: (p.m.) Comments Monday 8:00 7:00 Tuesday 8:00 7:00 Wednesday 8:00 7:00 Thursday 8:00 7:00 Friday 8:00 5:00 Saturday Sunday
Langhorne
Days of the Week From: (a.m.) To: (p.m.) Comments Monday 8:00 5:00 Tuesday 8:00 5:00 Wednesday 8:00 5:00 Thursday 8:00 5:00 Friday 8:00 5:00 Saturday Sunday Feasterville
Days of the Week From: (a.m.) To: (p.m.) Comments Monday 8:00 7:00 Tuesday Wednesday 8:00 7:00 Thursday 8:00 7:00 Friday Saturday Sunday
Cedarbrook
Days of the Week From: (a.m.) To: (p.m.) Comments Monday 7:30 7:00 Tuesday 7:30 7:00 Wednesday 7:30 7:00 Thursday 7:30 7:00 Friday 7:30 4:00 Saturday Sunday
Scranton
Days of the Week From: (a.m.) To: (p.m.) Comments Monday 7:30 6:30 Tuesday 7:30 6:30 Wednesday 7:30 1:00 Thursday 7:30 6:30 Friday 7:30 1:00 Saturday Sunday
Plains
Days of the Week From: (a.m.) To: (p.m.) Comments Monday 7:30 6:30 Tuesday 7:30 6:30 Wednesday 7:30 5:30 Thursday 7:30 6:30 Friday 7:30 1:00 Saturday Sunday
Student Schedule Indicate which of the following best describes the typical student work schedule:
Varied schedules
Describe the schedule(s) the student is expected to follow during the clinical experience: The student follows the CI's schedule.
Staffing Indicate the number of full-time and part-time budgeted and filled positions:
Morrisville
Full-time budgeted Part-time budgeted Current Staffing
PTs 1 1 PTAs 1 1 Aides/Techs Others: Specify
Neshaminy Full-time budgeted Part-time budgeted Current Staffing
PTs 2 2 PTAs 1 1 Aides/Techs Others: Specify OT
Juniata Park
Full-time budgeted Part-time budgeted Current Staffing
PTs 3 0 3 PTAs 1 1 Aides/Techs Others: Specify
Northeast Full-time budgeted Part-time budgeted Current Staffing
PTs 4 4 PTAs 3 3 Aides/Techs Others: Specify OT
Rockledge Full-time budgeted Part-time budgeted Current Staffing
PTs 1 1 2 PTAs Aides/Techs Others: Specify
Bristol Full-time budgeted Part-time budgeted Current Staffing
PTs 3 1 4 PTAs 1 1 Aides/Techs Others: Specify
Feasterville
Full-time budgeted Part-time budgeted Current Staffing
PTs 1 1 PTAs Aides/Techs Others: Specify
Langhorne
Full-time budgeted Part-time budgeted Current Staffing
PTs 1 1 PTAs 1 1 Aides/Techs Others: Specify
Cedarbrook
Full-time budgeted Part-time budgeted Current Staffing
PTs 4 4 PTAs 1 1 Aides/Techs Others: Specify
Scranton
Full-time budgeted Part-time budgeted Current Staffing
PTs 1 1 PTAs Aides/Techs Others: Specify
Plains
Full-time budgeted Part-time budgeted Current Staffing
PTs 1 1 1.5 PTAs 1 1 Aides/Techs Others: Specify
Information About the Clinical Education Experience
Special Programs/Activities/Learning Opportunities
X Administration X Industrial/ergonomic PT X Quality Assurance/CQI/TQM
X Aquatic therapy X Inservice training/lectures Radiology X Athletic venue coverage Neonatal care Research experience X Back school Nursing home/ECF/SNF Screening/prevention X Biomechanics lab Orthotic/Prosthetic fabrication X Sports physical therapy X Cardiac rehabilitation X Pain management program X Surgery (observation) Community/re-entry
activities Pediatric-general (emphasis on): X Team meetings/rounds
Critical care/intensive care Classroom consultation X Vestibular rehab Departmental administration Developmental program X Women’s Health/OB-GYN Early intervention Cognitive impairment X Work
Hardening/conditioning Employee intervention X Musculoskeletal Wound care Employee wellness program X Neurological Other (specify below)
Group programs/classes X Prevention/wellness Home health program Pulmonary rehabilitation
Specialty Clinics Please mark (X) all specialty clinics available as student learning experiences.
Arthritis X Orthopedic clinic X Screening clinics Balance Pain clinic Developmental Feeding clinic X Prosthetic/orthotic clinic Scoliosis X Hand clinic Seating/mobility clinic Preparticipation sports Hemophilia clinic Sports medicine clinic Wellness Industry Women’s health Other (specify below)
Neurology clinic
Health and Educational Providers at the Clinical Site Please mark (X) all health care and educational providers at your clinical site students typically observe and/or with whom they interact. X Administrators Massage therapists Speech/language
pathologists Alternative therapies:
List: Nurses Social workers
Athletic trainers X Occupational therapists Special education teachers Audiologists Physicians (list specialties) X Students from other
disciplines Dietitians Physician assistants X Students from other physical
therapy education programs Enterostomal /wound
specialists Podiatrists Therapeutic recreation
therapists Exercise physiologists Prosthetists /orthotists Vocational rehabilitation
counselors Fitness professionals Psychologists
Health information
technologists Respiratory therapists
Availability of the Clinical Education Experience
Indicate educational levels at which you accept PT and PTA students for clinical experiences (Mark (X) all that apply).
Physical Therapist Physical Therapist Assistant X First experience: Check all that apply.
Half days Full days Other: (Specify)
X First experience: Check all that apply. Half days Full days Other: (Specify)
X Intermediate experiences: Check all that apply. Half days Full days Other: (Specify)
X Intermediate experiences: Check all that apply. Half days Full days Other: (Specify)
X Final experience X Final experience Internship (6 months or longer)
Specialty experience
PT PTA From To From To
Indicate the range of weeks you will accept students for any single full-time (36 hrs/wk) clinical experience.
1/09 12/09 1/09 12/09
Indicate the range of weeks you will accept students for any one part-time (< 36 hrs/wk) clinical experience.
1/09 12/09 1/09 12/09
Morrisville PT PTA Average number of PT and PTA students affiliating per year. Clarify if multiple sites.
2 1
Juniata Park
PT PTA Average number of PT and PTA students affiliating per year. Clarify if multiple sites.
2 0
Northeast PT PTA Average number of PT and PTA students affiliating per year. Clarify if multiple sites.
3 2
Rockledge PT PTA Average number of PT and PTA students affiliating per year. Clarify if multiple sites.
2 0
Bristol PT PTA Average number of PT and PTA students affiliating per year. Clarify if multiple sites.
2 0
Feasterville PT PTA Average number of PT and PTA students affiliating per year. Clarify if multiple sites.
2 0
Langhorne PT PTA Average number of PT and PTA students affiliating per year. Clarify if multiple sites.
2 1
Yes No Comments
X Is your clinical site willing to offer reasonable accommodations for students under ADA?
What is the procedure for managing students whose performance is below expectations or unsafe? Contact Clinical Coordinator of school, and discuss issues/policies.
Answer if the clinical center employs only one PT or PTA.
Explain what provisions are made for students if the clinical instructor is ill or away from the clinical site.
Clinical Site’s Learning Objectives and Assessment
Yes No X 1. Does your clinical site provide written clinical education objectives to students?
If no, go to # 3.
2. Do these objectives accommodate: X •1 The student’s objectives? X •2 Students prepared at different levels within the academic curriculum? X •3 The academic program's objectives for specific learning experiences? X •4 Students with disabilities?
X 3. Are all professional staff members who provide physical therapy services acquainted with the clinical site's learning objectives?
When do the CCCE and/or CI typically discuss the clinical site's learning objectives with students? (Mark (X) all that apply)
X Beginning of the clinical experience X At mid-clinical experience Daily X At end of clinical experience X Weekly X Other: as needed
Indicate which of the following methods are typically utilized to inform students about their clinical performance? (Mark (X) all that apply) X Written and oral mid-evaluation X Ongoing feedback throughout the clinical
X Written and oral summative final evaluation X As per student request in addition to formal and ongoing written & oral feedback
X Student self-assessment throughout the clinical
OPTIONAL: Please feel free to use the space provided below to share additional information about your clinical site (eg, strengths, special learning opportunities, clinical supervision, organizational structure, clinical philosophies of treatment, pacing expectations of students [early, final]). Our sites have recently began documentation on Therapy Source. All documentation is now performed on laptops. Each clinician has their own laptop. Students will be sharing those of their CI's. At NovaCare we understand that each clinical affiliation is different. We discuss goals and expectations of each student upon arrival. We modify as needed throughout their affiliations.
Part II. Information for Students Arranging the Experience
Yes No Comments
X 1. Do students need to contact the clinical site for specific work hours related to the clinical experience?
X 2. Do students receive the same official holidays as staff?
X 3. Does your clinical site require a student interview?
TBS 4. Indicate the time the student should report to the clinical site on the first day of the experience.
X 5. Is a Mantoux TB test (PPD) required? a) one step_________ (? check) b) two step_________ (? check) If yes, within what time frame?
X 6. Is a Rubella Titer Test or immunization required?
X 7. Are any other health tests/immunizations required prior to the clinical experience?
If yes, please specify:
8. How is this information communicated to the clinic? Provide fax number if required.
Copy sent with student information
9. How current are student physical exam records required to be?
X 10. Are any other health tests or immunizations required on-site? If yes, please specify:
X 11. Is the student required to provide proof of OSHA training?
X 12. Is the student required to provide proof of HIPAA training?
X 13. Is the student required to provide proof of any other training prior to orientation at your facility? If yes, please list.
X 14. Is the student required to attest to an understanding of the benefits and risks of Hepatitis-B immunization?
X 15. Is the student required to have proof of health insurance?
X 16. Is emergency health care available for students?
X a) Is the student responsible for emergency health care costs?
X 17. Is other non-emergency medical care available to students?
X 18. Is the student required to be CPR certified? (Please note if a specific course is required).
Yes No Comments
X a) Can the student receive CPR certification while on-site?
X 19. Is the student required to be certified in First Aid?
X a) Can the student receive First Aid certification on-site?
X 20. Is a criminal background check required (eg, Criminal Offender Record Information)? If yes, please indicate which background check is required and time frame.
X 21. Is a child abuse clearance required?
22. Is the student responsible for the cost or required clearances?
X 23. Is the student required to submit to a drug test? If yes, please describe parameters.
X 24. Is medical testing available on-site for students?
25. Other requirements: (On-site orientation, sign an ethics statement, sign a confidentiality statement.)
Housing
Yes No Comments
X 26. Is housing provided for male students? (If no, go to #32)
X 27. Is housing provided for female students? (If no, go to #32)
28. What is the average cost of housing?
29. Description of the type of housing provided:
30. How far is the housing from the facility?
31. Person to contact to obtain/confirm housing:
Name:
Address:
City:
State: Zip:
Phone: E-mail:
Yes No
Comments Co
32. If housing is not provided for either gender: a) Is there a contact person for information on housing in
the area of the clinic? Please list contact person and phone #.
Please contact center. At times, we can help with housing.
b) Is there a list available concerning housing in the area of the clinic? If yes, please attach to the end of this form.
Transportation
Yes No Comments
X 33. Will a student need a car to complete the clinical experience? X 34. Is parking available at the clinical center? No cost a) What is the cost for parking?
X 35. Is public transportation available?
36. How close is the nearest transportation (in miles) to your site? Varies on location of center
a) Train station? miles b) Subway station? miles c) Bus station? miles d) Airport? miles
37. Briefly describe the area, population density, and any safety issues regarding where the clinical center is located.
Mostly middle-class with high density.
38. Please enclose a map of your facility, specifically the location of the department and parking. Travel directions can be obtained from several travel directories on the internet. (eg, Delorme, Microsoft, Yahoo, Mapquest).
Meals
Yes No Comments
X 39. Are meals available for students on-site? (If no, go to #40) Breakfast (if yes, indicate
approximate cost)
Lunch (if yes, indicate approximate cost)
Dinner (if yes, indicate approximate cost)
X 40. Are facilities available for the storage and preparation of food? Stipend/Scholarship
Yes No Comments
X 41. Is a stipend/salary provided for students? If no, go to #43.
a) How much is the stipend/salary? ($ / week)
42. Is this stipend/salary in lieu of meals or housing?
43. What is the minimum length of time the student needs to be on the clinical experience to be eligible for a stipend/salary?
Special Information
Yes No Comments X 44. Is there a facility/student dress code? If no, go to # 45.
If yes, please describe or attach.
a) Specify dress code for men:
Dress pants with polo shirt and/or button down shirt, clean closed back/toe shoes
b) Specify dress code for women:
Dress pants with polo shirt and/or button down shirt, clean closed back/toe shoes
X 45. Do you require a case study or inservice from all students (part-time and full-time)?
X 46. Do you require any additional written or verbal work from the student (eg, article critiques, journal review, patient/client education handout/brochure)?
X 47. Does your site have a written policy for missed days due to illness, emergency situations, other? If yes, please summarize.
X 48. Will the student have access to the Internet at the clinical site? Limited to educational sites
Other Student Information
Yes No
X 49. Do you provide the student with an on-site orientation to your clinical site? (mark X below)
a) Please indicate the typical orientation content by marking an X by all items that are included.
X Documentation/billing X Review of goals/objectives of clinical experience X Facility-wide or volunteer orientation X Student expectations X Learning style inventory Supplemental readings X Patient information/assignments X Tour of facility/department X Policies and procedures (specifically outlined plan for emergency responses)