CLINICAL SITE INFORMATION FORM

Initial Date 07/30/2007

Revision Date 01/21/08 Person Completing CSIF Emily McDonald, PT, MPT

E-mail address of person completing CSIF

emcdonald@wtrc.com

Name of Clinical Center West Texas Rehabilitation Center

Street Address 4601 Hartford Street

City Abilene State

TX Zip 79605

Facility Phone 325 793-3400 Ext.

PT Department Phone 325 793-3441 adult 325 793-3452 peds

Ext.

PT Department Fax 325 793-3549 peds 325 793-3534 adult

PT Department E-mail

Clinical Center Web Address

www.westtexasrehab.org

Director of Physical Therapy

Bryan Lange, PT, Director of Adult Services Tammy Baxter, PT,MPT, Director of Pediatric Services

Director of Physical Therapy E-mail blange@wtrc.com ; tbaxter@wtrc.com

Center Coordinator of Clinical Education (CCCE) / Contact Person

Emily McDonald, PT, MPT

CCCE / Contact Person Phone 325 793-3409

CCCE / Contact Person E-mail emcdonald@wtrc.com

APTA Credentialed Clinical Instructors (CI) (List name and credentials)

0; 1 staff pending for course in 2008 Emily McDonald, PT, MPT

Other Credentialed CIs (List name and credentials)

Texas Physical Therapy Consortium – MACS Emily McDonald, PT, MPT; Beth Schaeffer, PT, DPT; Jodi Thomas, PT, DPT; Julie Childs, PTA

Indicate which of the following are required by your facility prior to the clinical education experience:

x Proof of student health clearance x Criminal background check x Child clearance x Drug screening x First Aid and CPR x HIPAA education x OSHA education x Other: Please list tb test; hepatitis b

Part I: Information For the Academic Program Information About the Clinical Site – Primary

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Information About Multi-Center Facilities

If your health care system or practice has multiple sites or clinical centers, complete the following table(s) for each of the sites. Where information is the same as the primary clinical site, indicate “SAME.” If more than three sites, copy, and paste additional sections of this table before entering the requested information. Note that you must complete an abbreviated resume for each CCCE. Name of Clinical Site

Street Address

City State Zip

Facility Phone Ext.

PT Department Phone Ext.

Fax Number Facility E-mail

Director of Physical Therapy

E-mail

CCCE

E-mail

Name of Clinical Site

Street Address

City State Zip

Facility Phone Ext.

PT Department Phone Ext.

Fax Number Facility E-mail

Director of Physical Therapy

E-mail

CCCE

E-mail

Name of Clinical Site

Street Address

City State

Zip

Facility Phone Ext.

PT Department Phone Ext.

Fax Number Facility E-mail

Director of Physical Therapy

E-mail

CCCE

E-mail

3

Clinical Site Accreditation/Ownership

Yes No Date of Last Accreditation/Certification

Is your clinical site certified/ accredited? If no, go to #3.

If yes, has your clinical site been certified/accredited by:

JCAHO

CARF 2007

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 Government Agency Hospital/Medical Center Owned Nonprofit Agency Physician/Physician Group Owned PT Owned PT/PTA Owned Other (please specify)

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

Wellness/Prevention/Fitness Program

ECF/Nursing Home/SNF Private Practice Other: Sports Clinic

Federal/State/County Health Rehabilitation/Sub-acute Rehabilitation

Clinical Site Location

Which of the following best describes your clinical site’s location?

Rural Suburban

Urban

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Information About the Clinical Teaching Faculty

ABBREVIATED RESUME FOR CENTER COORDINATORS OF CLINICAL EDUCATION Please update as each new CCCE assumes this position.

NAME: Emily McDonald, PT, MPT

Length of time as the CCCE: newly appointed 6 months

DATE: 07/30/2007

Length of time as a CI: 3

PRESENT POSITION: Senior Pediatric Physical Therapist (Title, Name of Facility)

Mark (X) all that apply: PT PTA Other, specify

Length of time in clinical practice: 4

LICENSURE: (State/Numbers) 1155059

APTA Credentialed CI Yes No

Other CI Credentialing Yes No

Eligible for Licensure: Yes No

Certified Clinical Specialist: Yes No

Area of Clinical Specialization: Pediatrics Other credentials: NDT Trained Pediatrics

SUMMARY OF COLLEGE AND UNIVERSITY EDUCATION (Start with most current): Tab to add additional rows.

SUMMARY OF PRIMARY EMPLOYMENT (For current and previous four positions since graduation from college; start with most current): Tab to add additional rows.

PERIOD OF EMPLOYMENT

EMPLOYER POSITION

FROM TO West Texas Rehabilitation Center Staff Physical

Therapist 01/2004 07/2007

West Texas Rehabilitation Center Senior Staff Physical Therapist

07/2007 present

INSTITUTION

PERIOD OF STUDY

MAJOR DEGREE

FROM TO

Northwestern State University , Louisiana 1996 2000 Biology BS

Eastern Washington University 2001 2003 Physical Therapy Masters of Physical Therapy

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CONTINUING PROFESSIONAL PREPARATION RELATED DIRECTLY TO CLINICAL TEACHING RESPONSIBILITIES (for example, academic for credit courses [dates and titles], continuing education [courses and instructors], research, clinical practice/expertise, etc. in the last three (3) years): Tab to add additional rows.

Course Provider/Location Date

Basic Clinical Instructor Certification Course Hardin-Simmons University May 22, 2004

Seating to Enhance Freedom Freedom Designs, INC San Antonio TX

October 7 & 8 2004

Practical Applications to Biomechanics of the Foot, Ankle and Lower Extremity

Brian Hoke, PT, SCS, Motivations, Inc Houston TX

November 12-14, 2004

Pediatric Seating Systems: More than Just Sitting Pediatric Alliance and Texas Tech Univ. Lubbock, TX

April 2 & 3, 2005

Brain Gym Region 14 Education Service Center Abilene TX

June 27, 2005

If you Can't Breathe, You Can't Function Angelo State University, San Angelo TX

June 2005

Ethics and Your Professional Responsibility TPTA Midwest Districk and Hardin-Simmons Univ Abilene TX

March 23, 2006

NDT/Bobath Treatment and Management of Individuals with CP

NDTA and Augusta State University Cedar Park, TX

Started July 2005, Completed April 2006

Linking Movement Science and Intervention III STEP Summary Seminar

TPTA Midwest District Abilene TX

April 2006

NDTA Annual Confrence NDTA Stamford CT Novemeber 2006

Sure Step: Redefining Dynamic Orthotic West TExas Rehab Center Abilene TX

January 9, 2007

Ethics and Your Professional Responsibility TPTA Midwest District and Hardin-Simmons Univ Abilene TX

February 22, 2007

Seating: Bottom to Top Freedon Design, INC Abilene TX

March 29 & 30 2007

NDTA Specialty Conference An Intermediate Level Gait Course

NDTA Tempe, AZ November 2-4 2007

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CLINICAL INSTRUCTOR INFORMATION

Provide the following information on all PTs or PTAs employed at your clinical site who are CIs. For clinical sites with multiple locations, use one form for each location and identify the location here. Tab to add additional rows.

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 of Clinical Teaching

List Certifications KEY: A = APTA credentialed. CI B = Other CI credentialing C = Cert. clinical specialist List others

APTA

Member Yes/No L/E/T

Number State of

Licensure

Emily McDonald, PT, MPT

Eastern Washington University

2003

MPT 4 3

B, NDT Trained Pediatrics

Yes

1155059

TX

Jodi Thomas, PT, DPT

Duke University 2005

DPT 2

1.5

B Yes

1162382

TX

Beth Schaeffer, PT, DPT

Hardin Simmons University

2000 MPT

6.5 2.5 B No

1138485

TX

Tammy Baxter, PT, MPT

Hardin Simmons University

2000 MPT

6.5 5.5 SIPT certified Yes

1138584

TX

Julie Childs, PTA

Vincennes University

1996

AA

11

5

B Yes

2031631

TX

Jennifer Downey Wilson, PT, MS

Medical College of Virginia

1995

MS

12

11

PCS

No

1156100

TX

Rachel Sullivan, PT, DPT

Hardin Simmons University

2005 DPT 2 6 months No 1166580 TX

Lori J L Boyd, PT, BS

University of New England

1993

BS

14

8

B

Yes

1086759

TX

Scott Werner, PT Texas Tech University

2003

MPT

4 0 C Yes

1151877

TX

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Clinical Instructors What criteria do you use to select clinical instructors? (Mark (X) all that apply):

APTA Clinical Instructor Credentialing No criteria Career ladder opportunity Other (not APTA) clinical instructor credentialing Certification/training course Therapist initiative/volunteer Clinical competence Years of experience: Number: 1 Delegated in job description Other (please specify): Demonstrated strength in clinical

teaching

How are clinical instructors trained? (Mark (X) all that apply)

1:1 individual training (CCCE:CI) Continuing education by consortia

Academic for-credit coursework No training

APTA Clinical Instructor Education and Credentialing Program

Other (not APTA) clinical instructor credentialing program

Clinical center inservices Professional continuing education (eg, chapter, CEU course)

Continuing education by academic program

Other (please specify):

Information About the Physical Therapy Service

Number of Inpatient Beds For clinical sites with inpatient care, please provide the number of beds available in each of the subcategories listed below: (If this does not apply to your facility, please skip and move to the next table.)

Acute care Psychiatric center Intensive care Rehabilitation center Step down Other specialty centers: Specify Subacute/transitional care unit Extended care Total Number of Beds 0

Number of Patients/Clients Estimate the average number of patient/client visits per day:

INPATIENT OUTPATIENT Individual PT Individual PT Adult: 12 – 20 8-hour day

Pediatrics 15 (10-hour day; 11 8-hour day Student PT Student PT By the end of the internship, the

full time student should be able to assume the load of the staff therapist.

Individual PTA Individual PTA Adult 10 – 16 ; Pediatrics 10 – 15/day (PTA works in the school district)

Student PTA Student PTA By the end of the clinical, the full time student should be able to assume the load of the staff therapist.

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PT/PTA Team PT/PTA Team Total patient/client visits per day Total patient/client visits per day Average in

Pedi (school included) 50 visits per day; Average in Adult: 30 – 38/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%) Click on the gray bar under rating to select from the drop down box. Rating Patient Lifespan Rating Continuum of Care

4 peds 0-12 years Critical care, ICU, acute 3 peds 13-21 years SNF/ECF/sub-acute 5 adult 22-65 years Rehabilitation 4 adult Over 65 years 5 Ambulatory/outpatient Home health/hospice 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%)

2. Check (√) those patient/client diagnostic sub-categories available to the student. Click on the gray bar under rating to select from the drop down box.

(1-5) Musculoskeletal

Acute injury 4 adult

Muscle disease/dysfunction

2 adult

Amputation 4 adult

Musculoskeletal degenerative disease

2 peds 3 adult

Arthritis 2 peds 4 adult

Orthopedic surgery

Bone disease/dysfunction Other: (Specify) 2 adult

Connective tissue disease/dysfunction

(1-5) Neuro-muscular

2 peds 2 adult

Brain injury 2 peds 2 adult

Peripheral nerve injury

2 adult

Cerebral vascular accident 2 peds 2 adult

Spinal cord injury

2 adult

Chronic pain 2 adult

Vestibular disorder

5 peds

Congenital/developmental Other: (Specify)

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2 peds

Neuromuscular degenerative disease

(1-5) Cardiovascular-pulmonary

Cardiac dysfunction/disease Peripheral vascular dysfunction/disease 2 peds

Fitness Other: (Specify)

Lymphedema Pulmonary dysfunction/disease

(1-5) Integumentary

Burns Other: (Specify) Open wounds Scar formation

(1-5) Other (May cross a number of diagnostic groups)

Cognitive impairment Organ transplant General medical conditions

3 adult Wellness/Prevention Geriatric Maintenance Exercise Program

2 adult

General surgery Other: (Specify)

2 peds

Oncologic conditions

Hours of Operation Facilities with multiple sites with different hours must complete this section for each clinical center.

Days of the Week From: (a.m.) To: (p.m.) Comments Monday 7:30 peds

8:00 adult services

6:30 peds 5:00 adult services

In pediatrics, 1 CI works 4 10-hour days; 2 pediatric CIs work 5 8-hour days; 3 adult CIs work 5 8-hour days.

Tuesday 7:30 peds 8:00 adult services

6:30 peds 5:00 adult services

Wednesday 7:30 peds 8:00 adult services

6:30 peds 5:00 adult services

Thursday 7:30 peds 8:00 adult services

6:30 peds 5:00 adult services

Friday 7:30 peds 8:00 adult services

6:30 peds 5:00 adult services

Saturday Sunday

Student Schedule Indicate which of the following best describes the typical student work schedule:

Standard 8 hour day Varied schedules depending on CI’s schedule

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Describe the schedule(s) the student is expected to follow during the clinical experience: See specifics above

Staffing Indicate the number of full-time and part-time budgeted and filled positions:

Full-time budgeted Part-time budgeted Current Staffing

PTs 12 3 10 PTAs 1 1 Aides/Techs 0 5 3 Others: Specify Departmental Secretaries

2 2

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Information About the Clinical Education Experience Special Programs/Activities/Learning Opportunities Please mark (X) all special programs/activities/learning opportunities available to students.

Administration Industrial/ergonomic PT Quality Assurance/CQI/TQM

Aquatic therapy Inservice training/lectures Radiology Athletic venue coverage Neonatal care as determined by

census and CI Research experience

Back school Nursing home/ECF/SNF Screening/prevention Biomechanics lab Orthotic/Prosthetic fabrication Sports physical therapy Cardiac rehabilitation Pain management program Surgery (observation)

schedule with CI Community/re-entry

activities Pediatric-general (emphasis

on):Private medical and school based

Team meetings/rounds Pediatrics, Adult

Critical care/intensive care Classroom consultation Vestibular rehab Departmental administration Developmental program Women’s Health/OB-GYN Early intervention Cognitive impairment Work

Hardening/conditioning Employee intervention Musculoskeletal Wound care Employee wellness program Neurological- pediatric, adult Other (specify below)

Group programs/classes Prevention/wellness Home health program Pulmonary rehabilitation

Specialty Clinics Please mark (X) all specialty clinics available as student learning experiences.

Arthritis Orthopedic clinic Screening clinics Balance Pain clinic Developmental Feeding clinic Prosthetic/orthotic clinic Scoliosis Hand clinic Seating/mobility clinic Preparticipation sports Hemophilia clinic Sports medicine clinic Wellness Industry Women’s health X Other (specify below)

Cleft Palate Clinic Observation only

Neurology clinic

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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.

Administrators Massage therapists Speech/language pathologists

Alternative therapies: List:

Nurses Social workers

Athletic trainers Occupational therapists Special education teachers Audiologists Physicians (list specialties)

Director of Industrial Rehabilitation has office on site for evaluation; emg Appointments are scheduled

Students from other disciplines

Dietitians Physician assistants 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

Others (specify below)

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Affiliated PT and PTA Educational Programs List all PT and PTA education programs with which you currently affiliate. Tab to add additional rows.

Program Name City and State PT PTA TTUHSC Lubbock TX Angelo State University San Angelo, TX Hardin Simmons University Abilene, TX University of Texas El Paso El Paso, TX Texas Woman's University Houston, TX Texas Woman's University Dallas, TX X UTHSCSA San Antonio, TX University of Texas Medical Branch Galveston, TX Texas State University San Marcus, TX UT Southwestern Dallas, TX Odessa College Odessa, TX Amarillo College Amarillo, TX St. Phillips College San Antonio, TX University of Nebraska Omaha, NE University of Miami Coral Gables, FL North Georgia College and State University Dahlonega, GA OUHSC Oklahoma City, OK Southwest Baptist University Bolivar, MO Medical University of South Carolina Charlston, SC University of Kansas Medical Center Kansas City, KS University of New England Protland, ME University of New Mexico Albuquerque, NM University of Mississippi Jackson, MS University of Kentucky Medical Center Lexington, KY State University of New York Syracuse, NY Northern Arizona University Flagstaff, AZ Idaho State University Pocatello, ID Florida A&M University Tallahassee, FL University of San Augustine St. Augustine, FL University of Tennessee Memphis, TN University of Utah Salt Lake City, UT Colby Community College Colby, KS

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 First experience: Check all that apply. First experience: Check all that apply.

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Half days Full days Other: (Specify)

Half days Full days Other: (Specify)

Intermediate experiences: Check all that apply. Half days Full days Other: (Specify)

Intermediate experiences: Check all that apply. Half days Full days Other: (Specify)

Final experience Final experience Internship (6 months or longer) Specialty experience Pediatrics

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. This is decided on a first come first served basis and staffing levels at this time. Regarding Pediatrics, avoiding shorter 6 week - 8 week internships during the June through August time period is recommended due to frequent cancellations and low census possibly limiting the experience. However, this is the time for all of our camps and summer activities for kids (information below).

any

any

any

any

Indicate the range of weeks you will accept students for any one part-time (< 36 hrs/wk) clinical experience.

0

0

0

0

PT PTA Average number of PT and PTA students affiliating per year. Clarify if multiple sites.

15: 10 Pediatrics; 5 Adult; 1 Industrial Rehab

2 Pediatrics

Yes No Comments

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? Issues with safety have not been encountered. The student is asked to establish goals for the internship. The student and the CI meet weekly to document the progress and performance using an in-house form. If performance issues arise, they are noted during these meetings and the student counseled. If failure is anticipated prior to or at midterm, the DCE or ACCE is notified and a plan is put in place to assist the student in achieving the goal of successfully completing the internship. The student, CI, CCCE, and DCE will continue to communicate progress or lack of progress in making a determination for passing or failure. Our experience has been successful with this strategy. If in an extreme case, if successfully completing the internship is not possible, the CCCE and CI will work with the DCE and student on exiting the internship. This has occurred once and was unrelated to safety or patient treatment.

Box will expand to accommodate response. Answer if the clinical center employs only one PT or PTA.

16

Explain what provisions are made for students if the clinical instructor is ill or away from the clinical site. Usually another staff therapist can cover the student while they see the CI's case load when appropriate

Box will expand to accommodate response.

17

Clinical Site’s Learning Objectives and Assessment

Yes No 1. Does your clinical site provide written clinical education objectives to students?

If no, go to # 3. The student will be emailed prior to starting the internship where the student will write their objectives and list learning style then email it back to the CCCE. If the student’s objectives need modified the CI and student will meet during their first week to re-write the objectives

2. Do these objectives accommodate: • The student’s objectives? • Students prepared at different levels within the academic curriculum? • The academic program's objectives for specific learning experiences? • Students with disabilities? 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)

Beginning of the clinical experience At mid-clinical experience Daily informally At end of clinical experience Weekly Other as needed

Indicate which of the following methods are typically utilized to inform students about their clinical performance? (Mark (X) all that apply)

Written and oral mid-evaluation Ongoing feedback throughout the clinical Written and oral summative final evaluation As per student request in addition to formal

and ongoing written & oral feedback 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]). The prospective student may intern in:

• Pediatrics only • Adult OP Department seeing clients with varied diagnoses (ortho, neuro, and geriatric); • Industrial Rehabilitation

We prefer the student intern full time in pediatrics and avoid splitting the internship with adult services. We will accept students full time in pediatric internships of 6 – 14 weeks depending on the school’s clinical education program. We will also accept students in first year clinical education experiences of 3 – 4 weeks. Facility We are housed in a freestanding outpatient facility in Abilene, TX providing outpatient services to adult and pediatric clients. Pediatrics is the foundation of the facility and this has expanded over 50+ years to include adults.

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We also have departments for Audiology, Orthotics and Prosthetics, and Durable Medical Equipment on the same campus. WTRC has a separate philanthropic foundation from which funds are allocated to assist clients in obtaining services when other funding has been exhausted or if current funding does not allow coverage for services or equipment. Students will be allowed to access these areas to experience the integrated services offered and how this benefits clients. Please visit our website: www.westtexasrehab.org. Pediatrics The Pediatric Department consists of OT, PT, and ST as well as a grant funded Parent Case Management Department. There are large treatment areas available as well as a dedicated and furnished SI gymnasium. The gymnasium has rubberized flooring, ball pit, climbing walls, cargo net, 4 ceiling hooks, ball pit, and zip line. There is a pool area with graduated depths to facilitate treatment of clients of a variety of heights and ages. A serial casting program is also provided. WTRC sponsors Camp REHAB in June of each year for up to 50 children with special needs. The Texas High School Rodeo Association Finals are held in Abilene and sponsor a Special Kids Rodeo. The Justin Snow Special Teamers Football Camp is held in July for 40 kids with special needs. The department is also involved in assisting in another camp, Camp Experience, for children up to 9 years of age with visual impairments offered during the month of August. We are also actively involved with our local Autism Walk held each April and King David’s Kids, a local support group for families and individuals with Autism. The department contracts with the Abilene ISD to serve 33 schools. We also contract with the only local medical center housing an NICU. Patients are followed in the NICU progressing to the clinic as needed.

Box will expand to accommodate response.

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Part II. Information for Students Use the check (√) boxes provided for Yes/No responses. For all other responses or to provide additional detail, please use the Comment box. Arranging the Experience

Yes No Comments

1. Do students need to contact the clinical site for specific work hours related to the clinical experience?

The student will receive a packet via email with a clinical confirmation letter informing them of their assigned CI, work hours. expected time of arrival on the first day and general information about the internship, faciilty, housing (if using).

2. Do students receive the same official holidays as staff?

3. Does your clinical site require a student interview?

4. Indicate the time the student should report to the clinical site on the first day of the experience.

This depends on the CI's schedule and will be communicated when the CI is assigned.

5. Is a Mantoux TB test (PPD) required? a) one step_________ (√ check) b) two step_________ (√ check) If yes, within what time frame?

6. Is a Rubella Titer Test or immunization required?

7. Are any other health tests/immunizations required prior to the clinical experience?

If yes, please specify:

hepatitis B

8. How is this information communicated to the clinic? Provide fax number if required.

Many schools send this information in a packet with the student bio,OSHA and HIPPA training, CPR, insurance criminal background check. FAX number for the CCCE is (325) 793-3549

9. How current are student physical exam records required to be?

start of their program is sufficient

10. Are any other health tests or immunizations required on-site? If yes, please specify:

11. Is the student required to provide proof of OSHA training?

12. Is the student required to provide proof of HIPAA training?

13. Is the student required to provide proof of any other training prior to orientation at your facility? If yes, please list.

CPR

20

14. Is the student required to attest to an understanding of the benefits and risks of Hepatitis-B immunization?

15. Is the student required to have proof of health insurance?

16. Is emergency health care available for students? Not in the facility, but EMS services are readily available with two medical centers with ER facilities.

a) Is the student responsible for emergency health care costs?

17. Is other non-emergency medical care available to students? Minor Emergency Clinics are available in the community.

18. Is the student required to be CPR certified? (Please note if a specific course is required).

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Yes No Comments

a) Can the student receive CPR certification while on-site?

19. Is the student required to be certified in First Aid?

a) Can the student receive First Aid certification on-site?

20. Is a criminal background check required (eg, Criminal Offender Record Information)? If yes, please indicate which background check is required and time frame.

21. Is a child abuse clearance required?

If internship is in pediatrics

22. Is the student responsible for the cost or required clearances?

23. Is the student required to submit to a drug test? If yes, please describe parameters.

24. Is medical testing available on-site for students?

25. Other requirements: (On-site orientation, sign an ethics statement, sign a confidentiality statement.)

On site orientation will occur with the CI during the first week.

Housing

Yes No Comments

26. Is housing provided for male students? (If no, go to #32) however, housing is provided on a first come first served and males and females will not be in the house together

27. Is housing provided for female students? (If no, go to #32) however, housing is provided on a first come first served and males and females will not be in the house together

28. What is the average cost of housing? 0

29. Description of the type of housing provided: small 3 bedroom, furnished, 1 bath home, with central air and heat, cable and internet access. Contact the CCCE for details and these may be sent to the student upon request. If a student has reserved the student housing, the detailed description

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is sent in the information packet with the clinical confirmation letter.

30. How far is the housing from the facility? within 5 miles

31. Person to contact to obtain/confirm housing:

Name: Emily McDonald, PT, MPT CCCE

Address: 4601 Hartford Street

Emily McDonald, PT CCCE

City: Abilene

State: TX

Zip: 79605

Phone: (325) 793-3452 (325) 793-3409

E-mail: emcdonald@wtrc.com

Yes No

Comments

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 #.

SAME AS ABOVE

b) Is there a list available concerning housing in the area of the clinic? If yes, please attach to the end of this form.

contact if this is needed

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Transportation

Meals

Yes No Comments

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)

40. Are facilities available for the storage and preparation of food?

Yes No Comments

33. Will a student need a car to complete the clinical experience? 34. Is parking available at the clinical center?

a) What is the cost for parking? no cost

35. Is public transportation available? NOT RECOMMENDED

36. How close is the nearest transportation (in miles) to your site?

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.

Abilene is the gateway to West Texas, home to 3 major private religious based universities; population 110+ k; with small rural halo communities; 3 hours from Dallas, Austin, and Lubbock; low crime rate.

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).

Will be sent to student per request Parking is located in a lot directly adjacent to the building and is less than 2 minutes walk for all departments

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Stipend/Scholarship

Yes No Comments

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?

WTRC does not provide a stipend.

Special Information

Yes No Comments

44. Is there a facility/student dress code? If no, go to # 45. If yes, please describe or attach.

Shoes with enclosed toes must be worn, socks, no sleeveless attire, no tight clothing. Casual Fridays are in place; jeans and a polo type shirt. No midriff showing front or back, conservative necklines. WOMEN: scrubs, khaki pants, dress blouse. Conservative necklines. MEN: Shirts with collars, scrubs, dress pants Students may participate in a number of camps if the fieldwork experience coincides with the dates of camps. The student will be informed if this is the case and whether their particular fieldwork experience will include participation in camp and appropriate dress code for camp. Bring a swim suit to treat in the pool – conservative with adequate coverage – one piece for woman and trunks for men

a) Specify dress code for men:

see above

b) Specify dress code for women:

see above

45. Do you require a case study or inservice from all students (part-time and full-time)?

The student may do a special project in lieu of an inservice. (produce a brochure, specialized programming for staff, classroom personnel, or

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parent/patient).

46. Do you require any additional written or verbal work from the student (eg, article critiques, journal review, patient/client education handout/brochure)?

The student will observe multidisciplinary treatments and interventions in other departments and is expected to evaluate the experience using a written format provided by the CI. The student will also have a medication assignment with a written report. Articles will be reviewed as well.

47. Does your site have a written policy for missed days due to illness, emergency situations, other? If yes, please summarize.

The student should notify the CI as soon as they know they will miss the day due to illness or emergency situation. Regarding missed days: we follow the PT or PTA program’s policy on missed days and make up.

48. Will the student have access to the Internet at the clinical site?

Other Student Information

Yes No

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.

Documentation/billing Review of goals/objectives of clinical experience Facility-wide or volunteer orientation Student expectations Learning style inventory Supplemental readings Patient information/assignments Tour of facility/department Policies and procedures (specifically

outlined plan for emergency responses)

Quality assurance Reimbursement issues Required assignments (eg, case study,

diary/log, inservice)

Other (specify below - eg, bloodborne pathogens, hazardous materials, etc.)

In appreciation... Many thanks for your time and cooperation in completing the CSIF and continuing to serve the physical therapy profession as clinical mentors and role models. Your contributions to learners’ professional growth and development ensure that patients/clients today and tomorrow receive high-quality patient/client care services.