·t I: Intiormatio

CLINICAL SITE INFORMATION FORM

Irmation For tile Academic PrOflTllmInitial Date 03-13-06

11 About the Clinical Site - PrimaryRevision Date 1-30-07

Person Completing CSIF

Angie Norman, PT

E-mai I address of person

Angie Norman@Vallevmed.orgcompleting CSIF Name of Clinical Center

Valley Medical Center

Street Address

400 South 43rd Street

City

RentonState I WAI Zip

98058

Facility Phone

(425) 228-3450Ext.

PT Department Phone

(425) 251-5165Ext.

PT Department Fax

(425) 656-4028

PT Department E-mail Clinical Center Web

www.Valleymed.orgAddress Director of Physical

Melinda Glass, Director of Rehabilitation ServicesTherapy Director of Physical Therapy E-mail

Melinda _Glass@valleymed.org

Center Coordinator of Clinical

Angie Norman, PTEducation (CCCE) / Contact Person CCCE / Contact Person Phone

(425) 251-5165

CCCE / Contact Person E-mail

Angie Norman@Valleymed.org

APT A Credentialed Clinical

Angie Norman, PTInstructors (CI) (List name and credentials)

Other Credentialed Cis(List name and credentials)Indicate which of the following are

XProof of student health clearance

required by your facility prior to the

XCurrent (2 years) Washington State Criminal background checkclinical education experience:

o Child clearance

o Drug screeningX

First Aid and CPR

o HIPAA educationo OSHA educationXOther: Please list Bloodborne Pathogen Training

TB testProof of immunizationID badge with first and last name and school

4

Valley Medical Center will require a Student Program Checklist to besigned by the ACCE and returned to Valley Medical Center prior toinitiation of the internship. The Checklist attests that the educationalprogram has the above information on file. It will be provided byValley Medical Center to the ACCE in a timely manner. ValleyMedical Center will not require copies of individual certifications.

5

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 ofthe sites. Where information is the same as the primary clinical site, indicate "SAME." Ifmore than three sites, copythis table before entering the requested information. Note that you must complete an abbreviated resume for eachCCCE.

Name of Clinical Site Valley Medical Center Children's Therapy

Street Address

3600 Lind Ave SW, Ste 160

City

RentonI State

WAI Zip198058

Facility Phone

(425) 228-3450Ext.

PT Department Phone

(425) 656-4215Ext.

Fax NumberI Facility E-mail

Director of Physical

Melinda Glass, OTRILE-mailMelinda_ Glass@valleymed.orgTherapy CCCE

Lauren AdamsE-mailLauren _Adams@valleymed.org

Name of Clinical Site

Street AddressCityI StateI ZipI

Facility Phone

Ext.

PT Department Phone

Ext.

Fax NumberI Facility E-mail

Director of Physical

E-mailTherapy CCCE

E-mail

Name of Clinical Site

Street AddressCityI StateI ZipI

Facility Phone

Ext.

PT Department Phone

Ext.

Fax NumberI Facility E-mail

Director of Physical

E-mailTherapy

CCCE

E-mail

6

Clinical Site Accreditation/Ownership

Yes No Date of LastAccred itatio n/Certifica tio nX

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

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

D JCAHO Also Total Joint Center, StrokeCenter and Bariatric centerCertifiedD

D CARF

X

D Government Agency (eg, CORP, PTIP, rehab agency,State

state, etc.) DD Other

Which of the following best describes the ownership categoryfor your clinical site? (check all that apply)

D Corporate/Privately OwnedD Government AgencyD Hospital/Medical Center OwnedDNonprofit AgencyD Physician/Physician Group OwnedD PT OwnedD PT/PTA OwnedI:8J Other (please specify) Public Hospital

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.B. Next, if appropriate, check (.J) up to four additional categories that describe the other clinical centers associated

with your facility.

I Acute Care/Inpatient HospitalXIndustrial/Occupational DSchool/Preschool ProgramFacility

Health FacilityX

Ambulatory Care/Outpatient DMultiple Level Medical XWe Ilness/Prevention/F itnessCenter

Program

DECF/Nursing Home/SNF DPrivate Practice DOther: Specify

DFederal/State/County Health DRehabi Iitation/S ub-acute

Rehabilitation

Clinical Site Location

Which of the following best describes your clinicalsite's location?

7

DRuralX Suburban

Durban

Information About the Clinical Teaching Faculty

ABBREVIATED RESUME FOR CENTER COORDINATORS OF CLINICAL EDUCATIONPlease uvdate as each new CCCE assumes this vasil·

NAME: Angie Norman Length of time as the CCCE: 3 years

DA TE: (mm/dd/yy) 06/1 1/08

Length of time as a CI: 13 years

PRESENT POSITION: PT III

Mark (X) all thatLength ofValley Medical Center

apply:time inXPT

clinicalDPTA

practice: 14D Other, specify

Y2 years

LICENSURE: (State/Numbers)

APT A Credentialed CIOther CI CredentialingWA, PTOO06459

Yes XNo D YesDNo X

Eligible for Licensure:

Yes XNoD

I Certified Clinical Specialist:YesDNoxD

Area of Clinical Specialization: Other credentials:

SUMMARY OF COLLEGE AND UNIVERSITY EDUCATION (Start with most current):

INSTITUTION

PERIOD OFMAJORDEGREESTUDY FROM

TO

Eastern Washington University

19921994Physical TherapyBS

University of Washington

19851990Zoology BS

SUMMARY OF PRIMARY EMPLOYMENT (For current and previous four positions since graduation fromcollege; start with most current):

EMPLOYER POSITIONPERIOD OFEMPLOYMENTFROM

TO

Valley Medical Center

PT III2003Present

Canterbury House (SNF)

PT20012003

Highline Community Hospital Specialty Center (acute care,

PT19972001TCU, acute rehab and sub acute brain injury rehabilitation) Providence St. Peter Hospital (acute care, inpatient rehab,

PT19941997home health)

8

CONTINUING PROFESSIONAL PREPARATION RELATED DIRECTLY TO CLINICAL TEACHINGRESPONSIBILITIES (for example, academic for credit courses [dates and titles], continuing education [courses andinstructors], research, clinical practice/expertise, etc. in the last three (3) years):

Course Provider/LocationDate

Contact CCCE directly for this list if desired

9

CLINICAL INSTRUCTOR INFORMATION

Provide the following infonnation on all PTs or PT As employed at your clinical site who are CIs. For clinical sites with multiple locations, use one formfor each location and identify the location here.

Name followed by credentials

PT/PT A ProgramYear ofHighestNo. ofNo. of YearsList Certifications L= Licensed, Number

(eg, Joe Therapist, OPT, OCS

from Which CIGraduationEarnedYears ofof ClinicalKEY: E= EligibleJane Assistant, PT A, BS)

GraduatedPhysicalClinicalTeachingA = APT A credentialed. CIAPTAT= Temporary

Therapy

Practice B = Other CI credentialingMember

Degree

C = Cert. clinical specialistYes/N 0L/EITState of

List others

NumberLicensure

Barbara Areggar, PT

Washington]99]MSPT17]5Outpatient Ortho LWA

University

Inpatient SupervisorPTOOOO5552Julie Fulton, PT

University of200]MPT76 Lymphedema YesLWA

Puget Sound

Outpatient NeuroPTOOOO8576Melissa Reed

University of]978PT3027Lymphedema LWA

Washington

Hand TherapyPTOOOO2262Robert Sancilio

D'Youville]995MSPT13]2Outpatient OrthoYesLWA

College

Back RehabPTOOOO

6721Susan GillCheepmanPT]989]9]0Outpatient OrthoYesLWA

University

PTOOOO

5609Angie Norman

EasternPT19941413Inpatient Acute CareYesLWA

Washington

PTOOOO

University

6459

Vicky Lerner

DukePT199414]2Vestibular RehabYesLWAWIC fitting

PTOOOOOutpatient Neuro 7254

Marianne WickUniversity ofPT1976]915Outpatient Neuro LWA

Washington

PTOOOO

2039John KincaidUniversity ofPT]992]6? Occupational HealthYesLWA

Washington

ServicesPTOOOO

5783

10

Jon Takagi University ofMSPT200082 Inpatient Acute Care LWAWashington

PTOOOO8384Tera Martin

University ofMSPT200264 Outpatient Ortho LWAWashington

PTOOOO7079Mai Haynes

WesternMSPT200087 Inpatient Acute Care LWAUniversity of

PTOOOOHealth Sciences

8260

Mathew HunkovicUniversity ofPT199414<1Oupatient Ortho LWA

Maryland -

OCS certifiedPT

Eastern Shore

LevellIl NAIOMT

Darlene Bumgarner

Green RiverPTA19891917Inpatient Acute Care N/A

Community CollegeClaude McCrimmonGreen RiverPTA1997119 Outpatient N/A

Community CollegeTanya Baldwin

Green RiverPTA1998104 Outpatient N/A

Community CollegeTamara PetersGreen RiverPTA199710lh5 Outpatient N/A

Community CollegeTanya Van Winkle

Green RiverPTA20061 1/2< 1Inpatient Acute CareNoN/A

Community College

11

Clinical Instructors

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

X APT A Clinical Instructor CredentialingDNo criteriaX

Career ladder opportunity DOther (not APT A) clinical instructor credentialingX

Certification/training course XTherapist initiative/volunteerX

Clinical competence XYears of experience: Number: > 1

DDelegated in job description DOther (please specify):

XDemonstrated strength in clinical

teaching

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

X 1:1 individual training (CCCE:CI)DContinuing education by consortia

Academic for-credit coursework

DNo training

X

APT A Clinical Instructor Education andDOther (not APTA) clinical instructor credentialingCredentialing Program - voluntary

programX

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

Continuing education by academicDOther (please specify):program

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, --- -- ----r -- --- ----. - -- ---- ------ ------/

Acute care 328Psychiatric center 0

Intensive care

16Rehabilitation center 0

Step down

4-6Other specialty centers: Specify 0

Subacute/transitional care unit

0

Extended care

0Total Number of Beds 348

Number of Patients/Clients

.INPATIENT OUTPATIENT

10-12

Individual PT Individual PT(depends upon area of

8-10

Student PT - at end of internship Student PTservice and individual

I 0-14

Individual PTA Individual PTAtherapist's schedule. Will10-12

Student PTA - at end of internship Student PTAfloat up to inpatient pm.)PT/PTA Team

PT/PTA Team

100-120Total patient/client visits per day Total patient/client visits per day

E . h ber of oatient/cl· d

12

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 RatingContinuum of Care

1

0-12 years (this population covered by3Critical care, ICU, acuteChildren's Therapy and NICU staff 2

13-21 years SNF /ECF /sub-acute

422-65 years Rehabilitation

5Over 65 years 3Am bulatory /outpatient

Home health/hosoiceWellness/fitness/industry

Patient/Client Diagnoses1. 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 (--1) those patient/client diagnostic sub-categories available to the student.

(1-5) Musculoskeletal

4

Acute injury 3Muscle disease/dysfunction2

Amputation 3Musculoskeletal degenerative disease3

Arthritis 4Orthopedic surgery2

Bone disease/dysfunction 0Other: (SpecifY)2

Connective tissue disease/dysfunction(1-5)

Neuro-muscular

2

Brain injury 2Peripheral nerve iniury4

Cerebral vascular accident 2Spinal cord iniury2

Chronic pain 3Vestibular disorderI

Congen italldevelopmental Other: (Specify)2

Neuromuscular degenerative disease(1-5)

Cardiovascular-pulmonary

4

Cardiac dysfunction/disease 4Peripheral vascular dysfunction/disease1

Fitness 0Other: (Specify)3

Lymphedema4

Pulmonary dysfunction/disease(1-5)

Integumentary

IBurns 0Other: (Specify)

2Open wounds

IScar formation

(1-5)

Other (May cross a number of diagnostic groups)

4

Cognitive impairment 2Organ transolant - as a comorbidity only4

General medical conditions 2Well ness/Prevention4

General surgery 0Other: (Soecifv)3

Oncologic conditions

13

Hours of OperatiollFacilities 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

8:005:00Therapist have varied schedules. Weekends

Tuesday

8:005:00are covered by rotating therapists.

Wednesday

8:005:00

Thursday

8:005:00Outpatient service hours are 7:00-6:30 M-F

Friday

8:005:00

Saturday

8:305:00

Sunday

8:305:00

Studellt Schedule

Indicate which of the following best describes the typical student work schedule:o Standard 8 hour dayX Varied schedules

Describe the schedule(s) the student is expected to follow during the clinical experience:The average is an eight hour day 8:30-5:00 Monday through Friday. Individual therapist work varied schedules. Astudent may be asked to match their CI schedule. They may be asked to work a confirmed 32 hour per week

schedule with additional opportunities set up to achieve a 40 work week, as available. This will be determined onan individual basis.

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

Full-time budgetedPart-time budgetedCurrent StaffingInpatient

InpatientPTs

II 716 total

PTAs

2 24 total

Aides/Techs

2 02 total

Others: Specify

Full-time budgetedPart-time budgetedCurrent StaffingOutpatient

OutpatientPTs

II 716 total

PTAs

3 14 total

Aides/Techs

1 0I total

Others: Specify

14

Information About the Clinical Education Experience

Special Programs/Activities/Learning Opportunities

Please mark (X) all special programs/activities/learning opportunities available to students.

0 Administration XIndustrial/ergonomic PT 0Qual ityAssurance/CQ I/TQ MX

Aquatic therapy XInservice training/lectures 0Radiology0 Athletic venue coverage XNeonatal (very limited) access 0Research experience0Back school 0Nursing home/ECF/SNF 0Screening/prevention0Biomechanics lab 0Orthotic/Prosthetic fabrication XSports physical therapy

0Cardiac rehabilitation 0Pain management program XSurgery (observation)

0 Com munityIre-entry XPediatric-general: at Children's XTeam meetings/roundsactivities

Therapy only (outpatient)X

Critical care/intensive care0Classroom consultation XVestibular rehab

0 Departmental administration0Developmental program XWomen's Health/OB-GYN

0 Early intervention 0Cognitive impairment XWork

Hardening/conditioning0 Employee intervention XMusculoskeletal XWound care

0 Employee wellness programXNeurological XOther (specify below)Lymphedema/hand clinicX

Group programs/classes XPrevention/wellness

0Home health program 0Pulmonary rehabilitation

Specialty Clinics

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

0 Arthritis 0Orthopedic clinic 0Screening clinics0Balance 0Pain clinic 0Developmental0 Feeding clinic 0Prosthetic/orthotic clinic 0Scoliosis

X

Hand clinic XSeating/mobility clinic (limited)0Preparticipation sports0 Hemophilia clinic 0Sports medicine clinic 0Wellness

0 Industry 0Women's health 0Other (specify below)

0Neurology clinic

15

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 withwhom they interact.

X Administrators 0Massage therapists XSpeech/languagepathologists0 Alternative therapies: XNurses XSocial workers

List: 0 Athletic trainers XOccupational therapists 0Special education teachers

0Audiologists XPhysicians (list specialties) XStudents from other

disciplinesXDietitians XPhysician assistants XStudents from other physical

therapv education programsX

Enterostomal /wound XPodiatrists 0Therapeutic recreationspecial ists

therapists

0 Exercise physiologistsXProsthetists /orthotists 0Vocational rehabilitationcounselorsX

Fitness professionals XPsychologists 0Others (specify below)

0Health information XRespiratory therapists

technologists

Affiliated PT and PT A Educational ProgramsList all PT and PTA education programs with which you currently affiliate.

Program Name City and StatePTPTA

University of Washington

Seattle, WAX0University of Puget Sound

Tacoma, WAX0Eastern Washington University

Cheney, WAX0Green River Community College

Auburn, WA0X

University of Montana

MOX

University of the Pacific

CAX0Western University of Health Sciences

CAX

Texas Women's University

TXX0University of Idaho

IDX00

00

00

00

00

00

00

00

0

16

A vailability of the Clinical Education Experience

Indicate educational levels at which you accept PT and PTA students for clinical experiences (Mark (X) all thatapply).

Physical Therapist Physical Therapist Assistant

First experience: Check all that apply.

First experience: Check all that apply.D Halfdays

D Half daysX Full days

X Full daysD Other: (Specify)

D Other: (Specify)

Intermediate experiences: Check all that apply.

Intermediate experiences: Check all that apply.D Half days

D Half daysX Full days

X Full daysD Other: (Specify)

D Other: (Specify)

X Final experience

X Final experience

D Internship (6 months or longer) D Specialty experience

PTPTAFrom

ToFromTo

Indicate the range of weeks you will accept students for any single

412412

full-time (36 hrslwk) clinical experience. (Note varied Therapist schedules impact hours/week)Indicate the range of weeks you will accept students for anyone part-

12 12

time « 36 hrs/wk) clinical experience.

PTPTA

A verage number of PT and PT A students affiliating per year.3-6 inpatient3-5

Clarify if multiple sites.3-4 pediatric

I adult outpatient

Yes No Comments

X

DIs your clinical site willing to offer reasonableaccommodations for students under ADA?

What is the procedure for managing students whose performance is below expectations or unsafe?ACCE advises CCCE. CCCE meets with CI to discuss management. Frequent feed back and goal setting times setbetween student and CI. Feedback loop then frequently between CI, CCCE, ACCE and student.

Answer if the clinical center employs only one PT or PT A.

Explain what provisions are made for students if the clinical instructor is ill or away from the clinical site.Multiple team members are willing and available to work with interns if there instructor is away. There are alsomultiple additional observational experiences.

17

Clinical Site's Learning Objectives and Assessment

Yes No

XDI. Does your clinical site provide written clinical education objectives to students?

Ifno, go to # 3.2. Do these objectives accommodate:

XD •The student's objectives?

XD •Students prepared at different levels within the academic curriculum?

XD •The academic program's objectives for specific learning experiences?

XD •Students with disabilities? (on an as needed basis)

XD3. 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) allthat apply)

X Beginning of the clinical experience XAt mid-clinical experience

DDaily XAt end of clinical experience

X

Weekly XOther PRN

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 XOngoing feedback throughout the clinical

X

Written and oral summative final evaluationXAs per student request in addition to formaland ongoing written & oral feedbackX

Student self-assessment throughout the clinicalXWeekly written goals and feedback, prn only

OPTIONAL: Please feel free to use the space provided below to share additional information about your clinicalsite (eg, strengths, special learning opportunities, clinical supervision, organizational structure, clinicalphilosophies of treatment, pacing expectations ofstudents [early, final]).

Surgery observation available (for total hip or knee only)Participation in community events available throughout the year. (bike helmet fittings, backpackawareness, Senior Fair, Career Fair, Bring Your Kids to Work Day, etc ... )Exposure to Team RoundsAquatic Therapy

18

1<

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

X

DI. Do students need to contact the clinical site for specific workRecommended two weekshours related to the clinical experience?

prior to internshipX

D2. Do students receive the same official holidays as staff?

DX3. Does your clinical site require a student interview?

4. Indicate the time the student should report to the clinical site on

To be determined on anthe first day of the experience.

individual basisX

D5. Is a Mantoux TB test (PPO) required?a)one step (1/ check)

b)two step__ X__ c..J check)

If yes, within what time frame?XD6.Is a Rubella Titer Test or immunization required?

X

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

Td, Tetanus, Oiptheria,If yes, please specify:

Hep B8.

How is this information communicated to the clinic? Provide Student Program Checklistfax number if required.

provided by VMC needs to besigned by ACCE. Individualcertifications not required.9.

How current are student physical exam records required to currentbe?

DX10. Are any other health tests or immunizations required on-site?

If yes, please specify:X

II. Is the student required to provide proof of OSHA training?Bloodborne pathogens

DX12. Is the student required to provide proof of HIPAA training?Provided on site

DX13. Is the student required to provide proof of any other training

prior to orientation at your facility?If yes, please list.X

D14. Is the student required to attest to an understanding of thebenefits and risks of Hepatitis-B immunization?X

D15. Is the student required to have proof of health insurance?

X

D16. Is emergency health care available for students?

X

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

X

D17. Is other non-emergency medical care available to students?

X

D18. Is the student required to be CPR certified?(Please note if a specific course is required).

20

Yes No Comments

D

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

DX19. Is the student required to be certified in First Aid?

D

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

X

D20. Is a criminal background check required (eg, Criminal Washington State - withinOffender Record Information)?

past two years prior toIf yes, please indicate which background check is required and

internshiptime frame. D

X21.Is a child abuse clearance required?

X

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

DX23. Is the student required to submit to a drug test?

If yes, please describe parameters.D

X24. Is medical testing available on-site for students? Only in instances of workrelated exposure25. Other requirements: (On-site orientation, sign an ethics

On site orientation with

statement, sign a confidentiality statement.)

Human Resources will occur

the first day of the internshipand will include privacystatements, etc ...

Housing

Yes No Comments

DX26. Is housing provided for male students? (If no, go to #32)

DX27. 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:

I Zip:Phone:

E-mail:

Yes

No Comments

21

32.If housing is not provided for either gender:

DX a) Is there a contact person for information on housing in

the area of the clinic?Please list contact person and phone #.D

X b) Is there a list available concerning housing in the area ofPlease reference Valley Medicalthe clinic? If yes, please attach to the end ofthis form.

Center Website for links

Transportation

Yes No Comments

X

D33. Will a student need a car to complete the clinical experience?Or public transportationX

D34. Is parking available at the clinical center? limited

a)

What is the cost for parking? free

X

D35. Is public transportation available?

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

5 miles

b)

Subway station? miles

c)

Bus station? ] block

d)Airport? miles

37. Briefly describe the area, population density, and any safetyissues regarding where the clinical center is located. No unusual safety issues

38. Please enclose a map of your facility, specifically the location

Map and parking directionsof the department and parking. Travel directions can be

will be mailed prior to eachobtained from several travel directories on the internet.

internship. Please reference(eg, Delorme, Microsoft, Yahoo, Mapquest).

Valley Medical Center websiteto access this information priorto internship confirmation.

Meals

Yes No Comments

X

39. Are meals available for students on-site? (If no, go to #40)Cafeteria available

Breakfast (if yes, indicate

$ 3-6approximate cost) Lunch (if yes, indicate

$ 5-7approximate cost) Dinner (if yes, indicate

$ 5-7approximate cost) X

D40. Are facilities available for the storage and preparation of food?Microwave and refrigerator

22

Stipend/Sell olars Itip

Yes No Comments

DX41. Is a stipend/salary provided for students? If no, go to #43.

a) How much is the stipend/salary? ($ / week)DX42. Is this stipend/salary in lieu of meals or housing?

43. What is the minimum length of time the student needs to be onthe clinical experience to be eligible for a stipend/salary?

Special Information

Yes No Comments

X

D44. Is there a facility/student dress code? Ifno, go to # 45. Lab jacket -loaners availableIf yes, please describe or attach.

Casual professional. Scruba)

Specify dress code for men: pants okay. No scrub tops.No skirts or shorts. Closed toeb)

Specify dress code for women: and heel on all shoes.

D

X45. Do you require a case study or inservice from all students Determined on an individual

(part-time and full-time)?

basis.

DX46. Do you require any additional written or verbal work from theWill support educational

student (eg, article critiques, journal review, patient/clientinstitution requirements.

education handout/brochure)?Additional assignments may

be given prn to facilitateprogression of internship.X47. Does your site have a written policy for missed days due toBased on circumstances and

illness, emergency situations, other? If yes, please summarize.educational institution policy.

X

D48. Will the student have access to the Internet at the clinical site?Very limited

Otlter Student Information

Yes No

X

D49. Do you provide the student with an on-site orientation to your clinical site?

(mark X

a) Please indicate the typical orientation content by marking an X by all items that are included.below) X

Documentation/billing XReview of goals/objectives of clinical experience

DFacility-wide or volunteer orientationXStudent expectations

XLearning style inventory XSupplemental readings

X

Patient information/assignments XTour of facility/department

X

Policies and procedures (specificallyXOther (specify below - eg, bloodborne pathogens,outlined plan for emergency responses)

hazardous materials, etc.) HIP AA, Healthstream (safetyX

Quality assurance and quality issues)

X

Reimbursement issues

X

Required assignments (eg, case study,diary/log, inservice)

23

In appreciation ...

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

24