clinical site information form - university of utahweb.utah.edu/ptcemusolino/csifs/helenhays.pdf ·...
TRANSCRIPT
CLINICAL SITE INFORMATION FORM
I. Information About the Clinical Site Date: 7/9/07Person Completing Questionnaire Mary Nishimoto
E-mail address of person completing questionnaire [email protected]
Name of Clinical Center Helen Hayes Hospital
Street Address Route 9W
City West Haverstraw State NY Zip 10992
Facility Phone (845) 786-4000 Ext.
PT Department Phone (845) 786-4208 Ext.
PT Department Fax (845) 786-4022
PT Department E-mail The department secretary:
Web Address www.HelenHayesHospital.org
Director of Physical Therapy Jackie Velez, PT
Director of Physical Therapy E-mail [email protected]
Center Coordinator of Clinical Education (CCCE) / Contact Person
Mary Nishimoto, PT, DPT, NCS, CCCE
CCCE / Contact Person Phone (845) 786-4792
CCCE / Contact Person E-mail [email protected]
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Complete the following table(s) if there are multiple sites that are part of the same health care system or practice. Copy this table before entering information if you need more space. 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
Center Coordinator of Clinical Education/contact (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
Center Coordinator of Clinical Education/contact (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
Center Coordinator of Clinical Education/contact (CCCE)
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Clinical Site Accreditation/Ownership
Yes No Date of Last Accreditation/Certification
x 1. Is your clinical site certified/ accredited? If no, go to #3.
2. If yes, by whom?
x JCAHO 2005
x CARF 2006
x Government Agency (eg, CORF, PTIP, rehab agency, state, etc.)
Other
3. Who or what type of entity owns your clinical site? ____ PT owned ____ Hospital Owned ____ General business / corporation _x__ Other (please specify)_New York State____
4. Place the number 1 next to your clinical site’s primary classification -- noted in bold type. Next, if
appropriate, mark (X) up to four additional bold typed categories that describe other clinical centers associated with your primary classification. Beneath each of the five possible bold typed categories, mark (X) the specific learning experiences/settings that best describe that facility.
Acute Care/Hospital Facility Functional Capacity Exam- FCE X spinal cord injury university teaching hospital industrial rehab X traumatic brain injury pediatric other (please specify) X other cardiopulmonary Federal/State/County Health School/Preschool Program orthopedic Veteran’s Administration school system other pediatric develop. ctr. preschool program
X Ambulatory Care/Outpatient adult develop. ctr. early intervention X geriatric other other X hospital satellite Home Health Care X Wellness/Prevention Program medicine for the arts Agency X on-site fitness center X orthopedic contract service other pain center hospital based X Other X pediatric other international clinical site podiatric 1 Rehab/Subacute Rehab administration X sports PT X Inpatient X research X Other (Transitional Living Center) X Outpatient other
X ECF/Nursing Home/SNF X Pediatric Ergonomics X Adult work hardening/conditioning X Geriatric
4a. Which of these best characterizes your clinic’s location? Indicate with an ‘X’.
rural suburban X urban
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5. If your clinical site provides inpatient care, what are the number of:
18 Acute beds ECF beds Long term beds Psych beds 112 Rehab beds Step down beds 25 Subacute/transitional care unit 10 Other beds
(please specify): Transitional Living 165 Total Number of Beds
II. Information about the Provider of Physical Therapy Service at the Primary Center
6. PT Service hours
Days of the Week From: (a.m.) To: (p.m.) Comments
Monday 8:00 4:30 In-Patient services are
Tuesday 8:00 4:30 scheduled from 8a–4:30p
Wednesday 8:00 4:30 Monday through Friday.
Thursday 8:00 4:30 Modified on weekends.
Friday 8:00 4:30 Out-Patient ortho, neuro, and pediatrics are
Saturday 8:00 4:30 scheduled from 7a-8p
Sunday 8:00 4:30 Monday through Friday. 7. Describe the staffing pattern for your facility: Standard 8 hour day_67%___ Varied schedules__33%__
(Enter additional remarks in space below, including description of weekend physical therapy staffing pattern). Inpatient areas are staffed for standard 8 hour day. Out-patient areas may have varied schedules. Weekend in-patient therapy 8:00 – 4:30 with staff covering on a rotating basis.
8. Indicate the number of full-time and part-time budgeted and filled positions:
Full-time budgeted Part-time budgeted
PTs 23 19
PTAs 12 3
Aides/Techs 9
9. Estimate an average number of patients per therapist treated per day by the provider of physical therapy.
INPATIENT OUTPATIENT
8 Individual PT 10 Individual PT
10 Individual PTA 12 Individual PTA
115 Total PT service per day 130 Total PT service per day
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III. Available Learning Experiences 10. Please mark (X) the diagnosis related learning experiences available at your clinical site: X Amputations Critical care/Intensive care X Neurologic conditions X Arthritis X Degenerative diseases X Spinal cord injury X Athletic injuries X General medical conditions X Traumatic brain injury Burns X General surgery/Organ Transplant X Other neurologic conditions X Cardiac conditions X Hand/Upper extremity X Oncologic conditions X Cerebral vascular accident X Industrial injuries X Orthopedic/Musculoskeletal X Chronic pain/Pain ICU (Intensive Care Unit) X Pulmonary conditions X Connective tissue diseases X Mental retardation X Wound Care X Congenital/Developmental Other (specify below)
11. Please mark (X) all special programs/activities/learning opportunities available to students during clinical
experiences, or as part of an independent study. X Administration Industrial/Ergonomic PT X Prevention/Wellness X Aquatic therapy X Inservice training/Lectures X Pulmonary rehabilitation Back school Neonatal care X Quality Assurance/CQI/TQM Biomechanics lab X Nursing home/ECF/SNF X Radiology X Cardiac rehabilitation On the field athletic injury X Research experience X Community/Re-entry activities X Orthotic/Prosthetic fabrication Screening/Prevention Critical care/Intensive care X Pain management program X Sports physical therapy X Departmental administration Pediatric-General (emphasis on): Surgery (observation) Early intervention Classroom consultation X Team meetings/Rounds X Employee intervention X Developmental program X Women’s Health/OB-GYN X Employee wellness program X Mental retardation Work Hardening/Conditioning X Group programs/Classes X Musculoskeletal X Wound care Home health program X Neurological Other (specify below)
12. Please mark (X) all Specialty Clinics available as student learning experiences.
Amputee clinic Neurology clinic Screening clinics Arthritis Orthopedic clinic Developmental Feeding clinic Pain clinic Scoliosis Hand clinic Preparticipation in sports Sports medicine clinic Hemophilia Clinic X Prosthetic/Orthotic clinic Other (specify below) Industry X Seating/Mobility clinic
13. Please mark (X) all health professionals at your clinical site with whom students might observe and/or interact. X Administrators X Health information technologists X Psychologists
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Alternative Therapies X Nurses X Respiratory therapists Athletic trainers X Occupational therapists X Therapeutic recreation
therapists X Audiologists X Physicians (list specialties) X Social workers X Dietitians X Physician assistants Special education teachers
Enterostomal Therapist Podiatrists X Vocational rehabilitation counselors
X Exercise physiologists X Prosthetists /Orthotists Others (specify below)
14. List all PT and PTA education programs with which you currently affiliate.
Andrews University Armstrong Atlantic Boston University College Misericordia Columbia University Creighton University CUNY Hunter College Daemen College Dominican College Ithaca College Long Island University Massachusetts Bay Community College Medical College of Pennsylvania Mercy College Nassau Community College New York Medical College New York University Newbury College Northeastern University Nova Southeastern University Orange Community College Quinnipiac College Russell Sage College Sacred Heart University Shenandoah University Springfield College Suffolk Community College SUNY Buffalo SUNY Downstate SUNY Stony Brook SUNY Syracuse Touro College University of Connecticut University of Delaware Univ of Medicine and Dentistry of New Jersey UMDNJ – Rutgers University of Rhode Island University of the Sciences in Philadelphia University of Scranton University of Saint Augustine University of Vermont Utica College
15. What criteria do you use to select clinical instructors? (mark (X) all that apply):
X APTA Clinical Instructor Credentialing X Demonstrated strength in clinical teaching X Career ladder opportunity No criteria X Certification/Training course X Therapist initiative/volunteer X Clinical competence X Years of experience X Delegated in job description Other (please specify)
16. How are clinical instructors trained? (mark (X) all that apply)
X 1:1 individual training (CCCE:CI) X Continuing education by consortia
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Academic for-credit coursework No training
X APTA Clinical Instructor Credentialing X Professional continuing education (eg, chapter, CEU course)
X Clinical center inservices Other (please specify)
Continuing education by academic program
17. On pages 9 and 10 please provide information about individual(s) serving as the CCCE(s), and on pages 11 and 12 please provide information about individual(s) serving as the CI(s) at your clinical site.
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ABBREVIATED RESUME FOR CENTER COORDINATORS OF CLINICAL
EDUCATION Please update as each new CCCE assumes this position.
NAME: Mary Nishimoto Length of time as the CCCE: 14 years
DATE: (mm/dd/yy) 7/30/07 Length of time as the CI: 27 years
PRESENT POSITION: (Title, Name of Facility) Associate Director of Physical Therapy CCCE Helen Hayes Hospital
Mark (X) all that apply: _X___PT ____PTA ____Other, specify
Length of time in clinical practice: 28 years
LICENSURE: (State/Numbers) New York: 6727-1
Credentialed Clinical Instructor: Yes___X___ No_______
Eligible for Licensure: Yes_X___ No____ Certified Clinical Specialist: NCS
Neurologic Clinical Specialist Area of Clinical Specialization:
DPT, NDT (adult and pediatric), FIM, CPR, CPI Other credentials:
SUMMARY OF COLLEGE AND UNIVERSITY EDUCATION (start with most current):
INSTITUTION
PERIOD OF STUDY
MAJOR DEGREE
FROM TO
A.T. Still University, Arizona University 8/04 8/05 tDPT
University of Maryland at Baltimore 9/77 6/79 Physical Therapy B.S.
University of Maryland, College Park 9/75 8/77 Pre - P.T. N/A
SUMMARY OF PRIMARY EMPLOYMENT (For current and previous four positions since graduation from college; start with most current):
PERIOD OF EMPLOYMENT
EMPLOYER POSITION
FROM TO
Helen Hayes Hospital Associate Director 12/91
Present
Unit Coordinator 6/86 11/91
Staff Therapist 10/83 5/86
Blythedale Childrens Hospital Staff Therapist 7/79 9/83
9
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 five years):
APTA CI Credentialing Course 10/04 Impact of Age and TBI 11/13/03
Diagnosis and Hypothesis Oriented Algorithm 11/10/03 Body Weight Supported Treadmill Ambulation in Stroke Recovery 10/7/03
Combining Pharmacologic and Physical Therapy to Enhance Stroke Recovery 10/31/03
Breathing and Coughing Techniques 9/8/03
Diffuse Axonal Injury 9/4/03 Traumatic Brain Injury 3/10/03
Integrated Medicine 2/28/03 Substance Abuse and Brain Injury 11/15/02
CPI Non-Violent Crisis Intervention 11/25/02 Modalities and Cancer Survivors 11/4/02
Clinical Implications of Lab Values 11/14/02 Spasticity Medications 1/14/02
Evaluation and Treatment of the Patient in a Coma 4/15/02 Managing the Difficult Family 12/6/01
IRF-PAI Training 1/8/02 Acoustic Neuroma 11/20/01
Vestibular System 12/4/01 Pain 11/1/01
Rhythmic Auditory Stimulation 11/13/01 Brain Injury Continuum of Care 11/16/01
Cranial Sacral Therapy 3/17/02 Vision 10/19/00
Eccentric, Concentric, and Resisted Exercises with patient post Stroke. 12/4/00
Myofacial Release 9/11/00
The Cervical Spine 10/16/00 A Study of Pool Therapy in TKR Rehab 6/12/00
Motor Learning 6/19/00 Aquatics and Physical Therapy 3/6/00
NDT Review 5/8,15/00 Contemporary vs. Traditional Rehab 10/14/99
Chronic Pain Management 1/10/00 Balance Assessments 5/20/99
Mulligan Approach 5/10/99 Lite Gait Body Weight Support 4/26/99
Brain Tumors 4/19/99 Coma 4/8/99
The Pusher Syndrome 3/31/99 Clinical Performance Instrument 7/99
Lesion Specific Neuropathy 3/18/99 Management Communication 1/14/99
Customer Satisfaction 1/11/99 Fibromyalgia 8/2/99
Problem Based Learning 8/96 Education and Technology 3/96
Collaborative Learning 1/94 Negotiation and Conflict Resolution 1/92
Completed tDPT AT Still University 8/05 FIM Credential training 3/06
10
Neuro Research 9/05 Pharmacology 7/05
NVCI CPI Certif 7/05
11
ABBREVIATED RESUME FOR CENTER COORDINATORS OF CLINICAL EDUCATION
Please update as each new CCCE assumes this position.
NAME: Elaine DeFrancesco Length of time as the CCCE: 2 years
DATE: (mm/dd/yy) 8/22/06 Length of time as the CI: 7 years
PRESENT POSITION: (Title, Name of Facility) Associate Director of Physical Therapy Helen Hayes Hospital
Mark (X) all that apply: _X___PT ____PTA ____Other, specify
Length of time in clinical practice: 10 years
LICENSURE: (State/Numbers) New York: 016581-1
Credentialed Clinical Instructor: Yes______ No__X_____
Eligible for Licensure: Yes_X___ No____ Certified Clinical Specialist:
Area of Clinical Specialization:
Other credentials:
SUMMARY OF COLLEGE AND UNIVERSITY EDUCATION (start with most current):
INSTITUTION
PERIOD OF STUDY
MAJOR DEGREE
FROM TO
Rutgers/UMDNJ 6/94 6/96 Physical Therapy MPT
Fairfield University 9/90 5/94 Biology B.S.
SUMMARY OF PRIMARY EMPLOYMENT (For current and previous four positions since graduation from college; start with most current):
PERIOD OF EMPLOYMENT
EMPLOYER POSITION
FROM TO
Helen Hayes Hospital Associate Director 8/05
Present
Unit Coordinator 7/98 7/05
Staff Therapist 6/96 6/98
Palisades Rehabilitation Services for Women Per diem therapist 5/05 present
St Luke’s Roosevelt – Multiple Sclerosis Clinic Consultant 5/02 Present
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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 five years):
Assessor in Aventis Clinical Protocol Research Study to “Assess the effectiveness of the drug HP184 on subjects with Chronic SCI”. 12//2004 to present
A Symposium On SCI 9/05
Pelvic Dysfunction: Level 1 1/04 SI Evaluation: A Rocabado 11/04
Anatomy Review Course “Issues in Women’s Health” 1/03
Breathing and Coughing Techniques 9/8/03
HRI Certificate Completion 8/02 Beyond The Pelvic Floor 10/01
Breathing: Is It really Necessary” 10/01 Med-Trade Equipment Conference 98, 99
IRF-PAI Training 1/8/02 SCI Symposium 6/00
Pain 11/1/01 Introduction to Adult Hemiplegia 3/97
A Study of Pool Therapy in TKR Rehab 6/12/00 Spasticity Management for the MS Population 6/98
Balance Assessments 5/20/99 Respiratory management of the SCI Patient 4/98
Lite Gait Body Weight Support 4/26/99
Clinical Performance Instrument 7/99
SCI Symposium 9/06
13
CLINICAL INSTRUCTOR INFORMATION Provide the following information on all PTs or PTAs employed at your clinical site who are CIs.
L= Licensed, Number E= Eligible T= Temporary
Name
School from Which CI
Graduated
PT/PTA
Year of
Graduation
No. Of
Years of Clinical Practice
No. Of
Years of Clinical
Teaching
Credentialed CI Specialist Certification Other
L/E/T Number
State of Licensure
JACQUELINE VELEZ SIMMONS COLLEGE PT 1994 13 12 Credentialed CI L014299-1
NY
ELAINE DEFRANCESCO UMDNJ, RUTGERS PT 1996 11 10 Credentialed CI L016581-1
NY
MARY NISHIMOTO U. MARYLAND, BALT: BS ATSU: DPT
PT 1979 28 27 Credentialed CI NCS NDT, ADULT NDT, PEDIATRICS CPI-NVCI
L006727-1
NY
MARIE KELLY NYU: BS U. INDIANAPOLIS
PT MHS
1978 2002
29 28 OCS FAAOMT
L005921-1
NY
JODI BRANGACCIO SUNY, BUFFALO SPORTS/EXER SCIENCE
PT BS
1996 1996
11 10 Credentialed CI ACSM Coach Cert. Plyometric Certif.
L016290-1
NY
MICHELLE CARAVANO TOURO COLLEGE PT 1998 9 8 Credentialed CI
L019073-1
NY
MARY WAINWRIGHT NORTHEASTERN UNIV PT 1992 15 14 Credentialed CI NCS
L013272-1
NY
14
STACEY TWOGUNS NEW YORK MED COL PT 1998 9 8 L018662-1
NY
LORI TILLINGHAST SPRINGFIELD COL PT 1997 10 9 Credentialed CI CPI-NVCI
L017563-1
NY
PEG MEISLER NYU
PT 1990 17 16 Credentialed CI CCS
L011587-1
NY
IRENE LAWLOR NORTHEASTERN UNIV PT 1992 15 14 L025237-1
NY
JEANINE REGGIE PHIL COL PHARM & SCI PT 1993 14 13 Credentialed CI
L019146-1
NY
STACEY RITTENBERG NOVA SOUTHEASTERN PT 1997 10 9 Credentialed CI
L018374-1
NY
MARY BARRETT
HUNTER COLLEGE PT 1979 28 27 L006316-1
NY
ANNA TURNEY NYU PTA 1983 15 7 L000749-1
NY
LUBA STAROSTIAK HUNTER COLLEGE PT 1991 14 13 OCS L012548-1
NY
CAROLYN STORMS ITHACA COLLEGE LIU Exer. Physiology
PT MS
1988 1992
19 18 L010491-1
NY
15
BETH DUGGAN COLUMBIA UNIVER PT 1994 13 12 OCS L009921-1
NY
TOVA LEHMAN HUNTER COLLEGE TOURO COLLEGE: MS U. St. AUGUSTINE: DPT
PT
1997 2001 2006
10 9 OCS MTC
L017871-1
NY
STEPHEN RODRIGUEZ SUNY UPSTATE MED U. PT 2000 6 3 CMPT L022896-1
NY
MICHAEL GALLUCI NEW YORK UNIVERSITY NYMC: MS COLUMBIA U.: EdD
PT 1983 1990 2007
23 22 L008069-1
NY
AMBER BERARDINELLI FISHER COLLEGE PTA 1996 10 7 CPI-NVCI L003381-1
NY
MARY BROPHY MERCY COLLEGE ORANGE COUNTY CC
PT PTA
2003 1978
27 21 Credentialed CI L000282-1
NY
JILL COTIER ORANGE CO COMM COL PTA 1990 17 1 L001592-1
NY
BARBARA CULLUM ORANGE COUNTY CC PTA 1999 6 3 L004611-1
NY
ELIZABETH CURRAN LONG ISLAND UNIVER PT 1998 9 8 L018763-1
NY
TRACY ZOLLO QUINNIPIAC PT 1997 9 8 L020031-1
NY
16
TAMMY GOEDKEN U SOUTHERN CALIF DPT 2001 6 5 Credentialed CI CPI-NVCI
L024972-1
NY
JAIME HARWOOD HUNTER COLLEGE PT 1994 9 6 L014627-1
NY
VIRGINIA LITTLE SPRINGFIELD COL PT 2000 7 6 Credentialed CI Cert. Pilates Instru.
L021634-1
NY
MAUREEN MALKMUS SUFFOLK COM COL PTA 1999 8 6 CPI-NVCI L004506-1
NY
NANCY MASON SUFFOLK COM COL PTA 1996 11 10 Credentialed CI L003324-1
NY
STEPHANIE MCCRORRY ORANGE COUNTY CC MERCY
PTA PT
1992 2001
10 6
9 -
L002100-1
NY
REGINA MITCHELL ORANGE COUNTY CC PTA 1986 19 18 L001053-1
NY
CATHY PARLIER SUNY BUFFALO, BS ORANGE COUNTY CC NEW SCH SOC RES, MPS
PTA
1979
28
26
L000590-1
NY
MICHAEL SCHNEYMAN ORANGE COUNTY CC PTA 1991 16 15 L001108-1
NY
BOZENA SZOSTAK ORANGE COUNTY CC MERCY COLLEGE
PTA PT
1998 2004
6 2
3 -
L027068-1
NY
17
JOHN URAL ORANGE COUNTY CC PTA 1994 12 11 L001821-1
NY
JOELLYN VENTURA ORANGE COUNTY CC PTA 1997 10 8 L003858-1
NY
DELALI GOKA NORTHEASTERN U. PT 2004 3 1 L026319-1
NY
ALEXSA MANDEL SIMMONS COLLEGE PT 2001 6 5 L023160-1
VANESSA HOLLAND BOSTON UNIVERSITY PT 1999 8 7 L020984-1
NY
MICHELLE MCLEOD U. OF CONNECTICUT PT 2005 2 1 CPI-NVCI L027418-1
NY
JACQUELINE MENDELSOHN ORANGE COMMUN COL PTA 2005 2 - P45459
CYNTHIA SCHMID COLL. MISERICORDIA PT 2000 7 6 Credentialed CI CPI-NVCI
L021756-1
NY
JENI ROHRBACK ORANGE COMUN. COL PTA 2001 6 - L005471-1
NY
KAREN MICHELLA MERCY COLLEGE PT 2003 4 3 L025147-1
NY
18
PATRICIA O’TOOLE NEW YORK UNIVERSITY PTA 1995 12 11 L003117-1
NY
19
18. Indicate professional 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 First experience
X Intermediate experiences Intermediate experiences X Final experience X Final experience X Internship
PT PTA
From To From To 19. Indicate the range of weeks you will accept students for any single full-time (36 hrs/wk) clinical experience.
8 16 6
20. Indicate the range of weeks you will accept students for any one part-time (< 36 hrs/wk) clinical experience.
NA NA
PT PTA 21. Average number of PT and PTA students affiliating per year. 12 4
22. What is the procedure for managing students with exceptional qualities that might affect clinical
performance (eg, outstanding students, students with learning/performance deficits, learning disability, physically challenged, visually impaired)?
The outstanding student could be provided with additional learning opportunities within their assigned areas, or may expand to new areas. Students with challenges that make performance difficult or slow are provided with additional supervisory guidance and structured learning as appropriate. Modifications to program, schedule, and/or equipment may be explored to best meet the students needs.
23. 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. Not applicable. Yes No
X 24. Does your clinical site provide written clinical education objectives to students? If no, go to # 27.
25. Do these objectives accommodate: X the student’s objectives? X students prepared at different levels within the academic curriculum? X academic program's objectives for specific learning experiences? X students with disabilities? X 26. Are all professional staff members who provide physical therapy services acquainted with the
site's learning objectives? 27. When do the CCCE and/or CI discuss the clinical site's learning objectives with students? (mark (X) all that apply)
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X Beginning of the clinical experience X At mid-clinical experience X Daily X At end of clinical experience X Weekly Other
28. How do you provide the student with an evaluation of his/her 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
Yes No
X Do you require a specific student evaluation instrument other than that of the affiliating academic program? If yes, please specify: CPI is use for all PT affiliates. PTA affiliates use affiliating academic program evaluation instrument.
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]).
Clinical Site Information Form
Information for Students - Part II I. Information About the Clinical Site
Yes No
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?
4. Indicate the time the student should report to the clinical site on the first day
of the experience: 8:00 am
Medical Information Yes No Comments
X 5. Is a Mantoux TB test required? a) one step_________ b) two step____X_____
5a. If yes, within what time frame? 2PPD’S in last 12 months.
X 6. Is a Rubella Titer Test or immunization required? X 7. Are any other health tests/immunizations required prior to the
clinical experience?
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a) If yes, please specify: MMR. If born after 1957, need 2 immunizations, or documentation of disease or titer.
8. How current are student physical exam records required to be?
On-going and up to date.
X 9. Are any other health tests or immunizations required on-site? a) If yes, please specify:
X 10. Is the student required to provide proof of OSHA training?
X 11. Is the student required to attest to an understanding of the benefits and risks of Hepatitis-B immunization?
X 12. Is the student required to have proof of health insurance?
X a) Can proof be on file with the academic program or health center?
X 13. Is emergency health care available for students?
X a) Is the student responsible for emergency health care costs?
X 14. Is other non-emergency medical care available to students?
X 15. Is the student required to be CPR certified? (Please note if a specific course is required).
X a) Can the student receive CPR certification while on-site?
X 16. Is the student required to be certified in First Aid?
X a) Can the student receive First Aid certification on-site?
Yes No Comments
X 17. Is a criminal background check required (eg, Criminal Offender Record Information)?
X a) Is the student responsible for this cost?
X 18. Is the student required to submit to a drug test?
X 19. Is medical testing available on-site for students?
Housing
Yes No Comments
X 20. Is housing provided for male students? Housing is automatically reserved for affiliates.
X for female students? (If no, go to #26)
$165.00 -> $0.0 21. What is the average cost of housing? Deposit is fully refunded after the affiliation.
22. 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 #).
b) Is there a list available concerning housing in the area of the clinic? If yes, please attach to the end of this form.
23. Description of the type of housing provided: Small, private room, in co-ed dormitory. Shared bathroom, kithchen, lounge areas,
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laundry (coin operated) and pay phone. Linens and towels provided. 24. How far is the housing from the facility? On-site. 25. Person to contact to obtain/confirm housing: Name: Mary Nishimoto
Address: Helen Hayes Hospital City: West
Haverstraw State: NY Zip: 10993
Transportation
Yes No
X 26. Will a student need a car to complete the clinical experience? X 27. Is parking available at the clinical center? $ Free a) What is the cost?
X 28. Is public transportation available?
29. How close is the nearest bus stop (in miles) to your site? On Campus. a) train station? 20 Miles b) subway station? NA 30. Briefly describe the area, population density, and any safety
issues regarding where the clinical center is located. HHH is located in Rockland County, NY, midway between New York City and Bear Mountain State Park. It overlooks the Hudson River, and offers a wide variety of cultural activities, as well as a multitude of outdoor sports. Shopping malls, theaters, restaurants, and places of worship are within easy access by car. The George Washington Bridge into Manhattan is about a 30 minute drive away.
No extraordinary safety issues exist.
31. Please enclose printed directions and/or a map to your facility. Travel directions can be obtained from several travel directories on the internet. (eg, Delorme, Microsoft, Yahoo). Directions are also included in the “Affiliation Guide” that is sent out to each student prior to the affiliation.
Meals Yes No Comments
X 32. Are meals available for students on-site? (If no, go to #33)
X Breakfast (if yes, indicate approximate cost) $3.00
X Lunch (if yes, indicate approximate cost) $4.00 - $7.00
X Dinner (if yes, indicate approximate cost)
X Vending machines and microwave ovens are available 24 hours a day. Kitchen area available in dormitory housing.
a) Are facilities available for the storage and preparation of food?
Stipend/Scholarship
23
Yes No Comments
X 33. Is a stipend/salary provided for students? If no, go to #36
$ a) How much is the stipend/salary? ($ / Week)
34. Is this stipend/salary in lieu of meals or housing?
35. 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 36. Is there a student dress code? If no, go to # 37.
The following are NOT acceptable: skin tight, see-through, or low cut apparel, blue jeans, shorts, sweatpants, tank tops, large decals or logos on shirts, shoes with open toes/heel, synthetic fingernails, dark nail polish and no gum chewing.
Students bring and wear white lab jacket or lab coat. Clothes are clean, pressed
and in good repair. A photo I.D. badge will be provided
and must be worn at all times.
a) Specify dress code for men: b) Specify dress code for women: Culottes or split skirts are
allowed if at least knee length and if worn with
stockings. X 37. Do you require a case study or inservice from all students? X 38. Does your site have a written policy for missed days due to
illness, emergency situations, other? Missed days are reported to
the Academic Institution, and management is determined by individual consultation with
school, CI, and CCCE.
Other Student Information Yes No
X 39. Do you provide the student with an on-site orientation to your clinical site? (mark X) a) What does the orientation include? (mark (X) all that apply)
X Documentation/billing X Required assignments (eg, case study, diary/log, inservice) Learning style inventory X Review of goals/objectives of clinical experience X Patient information/assignments X Student expectations X Policies and procedures X Supplemental readings Quality assurance X Tour of facility/department X Reimbursement issues X Other (specify below) Week one Student Clinic
orientation and inservicing. In appreciation... Many thanks for your time and cooperation in completing the CSIF and continuing to serve the physical therapy profession as clinical teachers and role models. Your contributions to students’ professional growth and development ensure that patients today and tomorrow receive high-quality patient care services.
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Index
Saving the Completed Form……………………………………………………………………………………………..Page 2
Affiliated PT and PTA Educational Programs ………………………………………………………………….Page 8 Arranging the Experience ……………………………………………………………………………………Page 15
Required Background……………………………………………………………………………...…...Page 16 Required Medical Tests…………………………………………………………………………………Page 15
Available Learning Experiences……………………………………………………………………..…………….. Diagnosis………………………………………………………………………………………………..Page 7 Health Professionals on Site………………………………………………………………………...…….Page 8 Specialty Clinics………………………………………………………………………………………....Page 7 Special Programs/Activities/Learning Opportunities……………………………………………………….Page 7
Center Coordinators of Clinical Education (CCCEs)……………………………………………………………… Education…………………………………………………………………………………………….….Page 9 Employment Summary……………………………………………………………...…………………....Page 9 Information……………………………………………………………………………………………...Page 9 Teaching Preparation…………………………………………………………………………………...Page 10
Clinical Instructors…………………………………………………………………………………………………. Information…………………………………………………………………………………………Page 11-12 Selection Criteria………………………………………………………………………………………...Page 8 Training…………………………………………………………………………………………………Page 8
Clinical Site Accreditation…………………………………………………………………………………..Page 5 Clinical Site Ownership……………………………………………………………………………………..Page 5 Clinical Site Primary Classification…………………………………………………………………………Page 5 Information about the Clinical Site……………………………………………………………………………..Page 3
Information about Physical Therapy Service at Primary Center……………………………………………………………………………………Page 6
Satellite Site Information…………………………………………………………………………………Page 4 Physical Therapy Service…………………………………………………………………………………………...
Hours……………………………………………………………………………………………………Page 6 Number of Patients………………………………….…………………………………………………... Page 6 Staffing…………………………………………………………………………………………………. Page 6
Student Information………………………………………………………………………………………………... Housing………………………………………………………………………………………………..Page 16 Meals………………………………………………………………………………………………….Page 17 Other…………………………………………………………………………………………………..Page 17 Stipends………………………………………………………………………………………………..Page 17
Transportation…....…………………………………………………………………………………….Page 17