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CLINICAL SITE INFORMATION FORM
I. Information About the Clinical Site Date ( 01 / 29 / 08 )Person Completing QuestionnaireEric D. Miller, PT, Cert. MDTE-mail address of person completing questionnaire HYPERLINK "mailto:emiller@performancephysicaltherapy.com" emiller@performancephysicaltherapy.comName of Clinical CenterPerformance Physical TherapyStreet Address2075 Barkley Blvd. Suite 200CityBellinghamStateWAZip98226Facility Phone360-733-4008Ext.PT Department PhoneSameExt.PT Department Fax 360-733-4064PT Department E-mail HYPERLINK "mailto:emiller@performancephysicaltherapy.com" emiller@performancephysicaltherapy.comWeb Address HYPERLINK "http://www.performancephysicaltherapy.com" www.performancephysicaltherapy.comDirector of Physical TherapyEric D. Miller, PT, DPT, Cert. MDTDirector of Physical Therapy E-mail HYPERLINK "mailto:emiller@performancephysicaltherapy.com" emiller@performancephysicaltherapy.comCenter Coordinator of Clinical Education (CCCE) /
Contact PersonSameCCCE / Contact Person Phone360-733-4008CCCE / Contact Person E-mail HYPERLINK "mailto:emiller@performancephysicaltherapy.com" emiller@performancephysicaltherapy.com 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 SitePerformance Physical Therapy Barkley Medical CenterStreet Address2075 Barkley Blvd. Suite 200CityBellinghamStateWAZip98226Facility Phone360-733-4008Ext.PT Department PhoneSameExt.Fax Number360-733-4064Facility E-mail HYPERLINK "mailto:emiller@performancephysicaltherapy.com" emiller@performancephysicaltherapy.comDirector of Physical TherapyEric D. Miller, PT,DPT, Cert MDT
E-mail SameCenter Coordinator of Clinical Education/contact (CCCE)SameE-mail Same
Name of Clinical SitePerformance Physical Therapy Bellingham Athletic ClubStreet Address1616 Cornwall Suite B`CityBellinghamStateWAZip98225Facility Phone360-714-0870Ext.PT Department PhoneSameExt.Fax Number360-714-0872Facility E-mail Director of Physical TherapyBrian J. Weeda, MS, PT, ATC
E-mail HYPERLINK "mailto:bjweeda@performancephysicaltherapy.com" bjweeda@performancephysicaltherapy.comCenter Coordinator of Clinical Education/contact (CCCE)Eric D. Miller, PT, DPT, Cert. MDTE-mail HYPERLINK "mailto:emiller@performancephysicaltherapy.com" emiller@performancephysicaltherapy.com
Name of Clinical SiteStreet AddressCityStateZipFacility PhoneExt.PT Department PhoneExt.Fax NumberFacility E-mail Director of Physical Therapy
E-mail Center Coordinator of Clinical Education/contact (CCCE)E-mail
Clinical Site Accreditation/Ownership
YesNoDate of Last Accreditation/CertificationX1. Is your clinical site certified/ accredited? If no, go to #3. 2. If yes, by whom? JCAHO CARFX Government Agency (eg, CORF, PTIP, rehab agency, state, etc.)1997 PTIP Initially ongoing thereafter as required by federal lawX OtherNorthwest Rehab Alliance (NCQA Credentialing agency & IPA). Most recent was August 2004.Who or what type of entity owns your clinical site?
__X_ PT owned
____ Hospital Owned
____ General business / corporation
____ Other (please specify)___________________
Place the number 1 next to your clinical sites 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 FacilityFunctional Capacity Exam- FCEspinal cord injuryuniversity teaching hospitalindustrial rehabtraumatic brain injurypediatricxother (please specify) off site work place evaluationsothercardiopulmonaryFederal/State/County HealthSchool/Preschool ProgramorthopedicVeterans Administrationschool systemotherpediatric develop. ctr.preschool program1Ambulatory Care/Outpatientadult develop. ctr.early interventiongeriatricother otherhospital satelliteHome Health CarexWellness/Prevention Programmedicine for the artsagencyxon-site fitness center BAC officexorthopediccontract serviceotherpain centerhospital basedOtherpediatricother international clinical sitexPodiatric including on site orthotic labRehab/Subacute Rehabadministrationxsports PTinpatientresearchotheroutpatientotherECF/Nursing Home/SNFpediatricxErgonomicsadultwork hardening/conditioninggeriatric
4a. Which of these best characterizes your clinics location? Indicate with an X. ruralsuburbanurbanX
If your clinical site provides inpatient care, what are the number of:
Acute bedsECF bedsLong term bedsPsych bedsRehab bedsStep down bedsSubacute/transitional care unitOther beds
(please specify):Total Number of Beds
Information about the Provider of Physical Therapy Service at the Primary Center
6. PT Service hours
Days of the WeekFrom: (a.m.)To: (p.m.)CommentsMonday66Tuesday66Wednesday66Thursday66Friday75SaturdaySunday
7. Describe the staffing pattern for your facility: Standard 8 hour day____ Varied schedules_X___
(Enter additional remarks in space below, including description of weekend physical therapy staffing pattern).
Will vary by therapist. Some work 10 hour shifts from 6 am, others until 6 pm. Some work a standard 8 hour day, others work part-time.
8. Indicate the number of full-time and part-time budgeted and filled positions:
Full-time budgetedPart-time budgetedPTs10/82/2PTAs2/20/0Aides/Techs2/21/1
9. Estimate an average number of patients per therapist treated per day by the provider of
physical therapy.
INPATIENTOUTPATIENTIndividual PT14Individual PTIndividual PTA10Individual PTATotal PT service per day70Total PT service per day
III. Available Learning Experiences
10. Please mark (X) the diagnosis related learning experiences available at your clinical site:
AmputationsCritical care/Intensive careNeurologic conditionsXArthritisxDegenerative diseases Spinal cord injuryXAthletic injuriesxGeneral medical conditions Traumatic brain injuryBurnsGeneral surgery/Organ Transplant Other neurologic conditionsCardiac conditionsHand/Upper extremityOncologic conditionsCerebral vascular accidentIndustrial injuriesxOrthopedic/MusculoskeletalChronic pain/PainICU (Intensive Care Unit)Pulmonary conditionsXConnective tissue diseasesMental retardationWound CareCongenital/DevelopmentalOther (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.
AdministrationxIndustrial/Ergonomic PTPrevention/WellnessAquatic therapyxInservice training/LecturesPulmonary rehabilitationBack schoolNeonatal carexQuality Assurance/CQI/TQMXBiomechanics labNursing home/ECF/SNFRadiologyCardiac rehabilitationOn the field athletic injuryResearch experienceCommunity/Re-entry activitiesxOrthotic/Prosthetic fabricationScreening/PreventionCritical care/Intensive carePain management programxSports physical therapyDepartmental administrationPediatric-General (emphasis on):xSurgery (observation)Early intervention Classroom consultationTeam meetings/RoundsEmployee intervention Developmental programxWomens Health/OB-GYNEmployee wellness program Mental retardationWork Hardening/ConditioningGroup programs/Classes MusculoskeletalWound careHome health program NeurologicalOther (specify below)
12. Please mark (X) all Specialty Clinics available as student learning experiences.
Amputee clinicNeurology clinicScreening clinicsArthritisOrthopedic clinic DevelopmentalFeeding clinicPain clinic ScoliosisHand clinicPreparticipation in sportsSports medicine clinicHemophilia ClinicProsthetic/Orthotic clinicOther (specify below)IndustrySeating/Mobility clinic
13. Please mark (X) all health professionals at your clinical site with whom students might observe and/or interact.
XAdministratorsHealth information technologistsPsychologistsAlternative TherapiesNursesRespiratory therapistsXAthletic trainersOccupational therapistsTherapeutic recreation therapistsAudiologistsPhysicians (list specialties)Social workersDietitiansPhysician assistantsSpecial education teachersEnterostomal TherapistPodiatristsVocational rehabilitation counselorsExercise physiologistsProsthetists /OrthotistsOthers (specify below)
14. List all PT and PTA education programs with which you currently affiliate.
Whatcom Community College PTA ProgramUniversity of Washington PT SchoolOhio University PT School
15. What criteria do you use to select clinical instructors? (mark (X) all that apply):
APTA Clinical Instructor CredentialingxDemonstrated strength in clinical teachingCareer ladder opportunityNo criteriaCertification/Training coursexTherapist initiative/volunteerXClinical competencexYears of experienceXDelegated in job descriptionOther (please specify)
16. How are clinical instructors trained? (mark (X) all that apply)
1:1 individual training (CCCE:CI)Continuing education by consortiaAcademic for-credit courseworkNo trainingAPTA Clinical Instructor CredentialingxProfessional continuing education (eg, chapter, CEU course)Clinical center inservicesOther (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.
ABBREVIATED RESUME FOR CENTER COORDINATORS OF CLINICAL EDUCATION
Please update as each new CCCE assumes this position.
NAME: Eric D. Miller, PT, DPT, Cert MDTLength of time as the CCCE: 11 yearsDATE: (mm/dd/yy) 1/29/2006Length of time as the CI: 14PRESENT POSITION:
Sec/Treas, Performance Physical Therapy, Inc
Clinical Director Barkley Medical OfficeMark (X) all that apply:
__X__PT
____PTA
____Other, specify
Length of time in clinical practice:
17 yearsLICENSURE: (State/Numbers): WA: PT00005691Credentialed Clinical Instructor:
Yes______ No___x____
Eligible for Licensure: Yes__x__ No____Certified Clinical Specialist:Area of Clinical Specialization:Other credentials: Certified Mechanical Diagnosis & Treatment McKenzie Institute USA
SUMMARY OF COLLEGE AND UNIVERSITY EDUCATION (start with most current):
INSTITUTION
PERIOD OF STUDY
MAJORDEGREEFROMTOSimmons College Graduate School of Health Sciences01/20055/2007Physical TherapyTransition DPTBowling Green State University in consortium with the Medical University of Ohio09/19865/1990Physical TherapyBSPTHesston College, Hesston KS09/198305/1985Liberal ArtsAA
SUMMARY OF PRIMARY EMPLOYMENT (For current and previous four positions since graduation from college; start with most current):
EMPLOYERPOSITIONPERIOD OF EMPLOYMENT
FROMTOPerformance Physical Therapy, Bellingham, WAOwner/Clinical Director1997
Present
Physiotherapy Associates Lynden, Lynden WAClinical Director19941997Physiotherapy Associates Northwest, Bellingham, WAStaff Therapist19921994Associated Therapy Centers, Toledo, OHStaff Therapist19901992CONTINUING 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):
Introduction to Hand Therapy
CSE - Barry Poole
Redondo Beach, CA - July 2000
Cervical Spine - Part B
McKenzie Institute USA - Nelson Coffey
Minneapolis, MN - March 2001
Lumbar Spine - Part A
McKenzie Institute USA - Audrey Long
Minneapolis, MN - March 2001
Corporate Compliance
NWRA - James Ball
Seattle, WA - May 2001
Building & Rebuilding the Athlete
Wynn Marketing - Vern Gambetta
Los Angeles, CA - March 2002
Current Concepts in Shoulder Conditions
PTWA - George Davies
Renton, WA - April 2002
Problem Solving - Part C
McKenzie Institute USA - Robert Medcalf
Lewisville, TX - March 2003
Ergonomic Evaluation Certification Program
Roy Matheson & Associates - John LaCourse
Vancouver, BC - September 2003
Advanced Problem Solving - Part D
McKenzie Institute USA - Mark Miller
Atlanta, GA - October 2004
L.T. Staheli Pediatric Orthopedic Seminar
Children's Hospital & Medical Center
Seattle, WA - January 2005
Human Extemities - Part E
McKenzie Institute USA - Mark Miller
Austin, TX - 2005
Coding & Reimbursement Seminar
APTA - Helene Fearon & Steve Levine
Seattle, WA - March 2006
CLINICAL INSTRUCTOR INFORMATION
Provide the following information on all PTs or PTAs employed at your clinical site who are CIs.
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= Licensed, Number
E= Eligible
T= TemporaryL/E/T
NumberState of
Licensure
Brian J. Weeda
Old Dominion UniversityMS, PT19921410L PT00006136WATheodore F. MolaskiNortheastern University
Simmons CollegePT
DPT1979
20062725L
PT00002984WANed HartleyUniversity of Saint AugustineMPT199794L
PT00007300WAAngela BeaupainUniversity of WashingtonPT199972L
PT00008050WA
Laurie BertscheUniversity of IndianapolisMS, PT200161L
PT00008414WA
18. Indicate professional educational levels at which you accept PT and PTA students for clinical
experiences (mark (X) all that apply).
Physical TherapistPhysical Therapist Assistantxfirst experienceFirst experiencexintermediate experiencesIntermediate experiencesxfinal experiencexFinal experiencexInternship
PTPTAFromToFromTo19. Indicate the range of weeks you will accept students for any single full-time (36 hrs/wk) clinical experience.4122820. Indicate the range of weeks you will accept students for any one part-time (< 36 hrs/wk) clinical experience.1818
PTPTA21. Average number of PT and PTA students affiliating per year.12
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)?
Currently, there is no standard procedure. We work closely with each ACCE to discuss the students needs prior to the placement as well as meeting one on one with the student on the first day as well as regular meetings after that time to ensure that the students, the educational institutions and the facilitys goals are being met.
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.
YesNox24. Does your clinical site provide written clinical education objectives to students?
If no, go to # 27.25. Do these objectives accommodate:x the students objectives? x students prepared at different levels within the academic curriculum?x academic program's objectives for specific learning experiences?x students with disabilities?x26. Are all professional staff members who provide physical therapy services acquainted with the clinical
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)
xBeginning of the clinical experiencexAt mid-clinical experiencexDailyxAt end of clinical experiencexWeeklyOther
28. How do you provide the student with an evaluation of his/her performance? (mark (X) all that apply)
Written and oral mid-evaluationxOngoing feedback throughout the clinicalxWritten and oral summative final evaluationAs per student request in addition to formal and ongoing written & oral feedbackxStudent self-assessment throughout the clinical
YesNoxDo you require a specific student evaluation instrument other than that of the affiliating academic program? If yes, please specify:
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]).
Performance Physical Therapy is a therapist owned private practice with 3 owners on site who are actively treating patients in addition to running a busy private practice. The clinicians working at Performance Physical Therapy have many years of experience (up to 25+) with sub specialty skills including: lower extremity biomechanics and orthotic lab fabrication, womens health, vestibular dysfunction, athletic trainers, certified McKenzie practioner, certified Strength and Conditioning Specialist, health club facility presence and ergonomics consulting. We have a close working relationship with area physicians are may be able to set up surgical observations as well as other educational opportunities.
Information for Students - Part II
I. Information About the Clinical Site
YesNox1. Do students need to contact the clinical site for specific work hours related to the clinical experience?x2. Do students receive the same official holidays as staff?x3. 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: 7:00 am
Medical Information
YesNoCommentsx5. Is a Mantoux TB test required?
one step_________
two step_________
As required by the educational institution5a. If yes, within what time frame? As abovex6. Is a Rubella Titer Test or immunization required?Only if required by the schoolx7. Are any other health tests/immunizations required prior to the clinical experience? a) If yes, please specify:8. How current are student physical exam records required to be?2 yearsx9. Are any other health tests or immunizations required on-site? a) If yes, please specify:x10. Is the student required to provide proof of OSHA training?x11. Is the student required to attest to an understanding of the
benefits and risks of Hepatitis-B immunization?x12. Is the student required to have proof of health insurance?xCan proof be on file with the academic program or health center?x13. Is emergency health care available for students?At student cost at the local hospitalx a) Is the student responsible for emergency health care costs?x14. Is other non-emergency medical care available to students?At student costx15. Is the student required to be CPR certified?
(Please note if a specific course is required).anyx a) Can the student receive CPR certification while on-site?x16. Is the student required to be certified in First Aid?x a) Can the student receive First Aid certification on-site?YesNoCommentsx17. Is a criminal background check required (eg, Criminal Offender Record Information)? a) Is the student responsible for this cost?x18. Is the student required to submit to a drug test?x19. Is medical testing available on-site for students?
Housing
YesNoCommentsx20. Is housing provided for male students?x for female students? (If no, go to #26)$21. What is the average cost of housing?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 #).No
b) Is there a list available concerning housing in the area of the clinic? If yes, please attach to the end of this form.No23. Description of the type of housing provided:24. How far is the housing from the facility?25. Person to contact to obtain/confirm housing: Name: Address: City:State:Zip:
Transportation
YesNox26. Will a student need a car to complete the clinical experience?Depending on the location of housingx27. Is parking available at the clinical center?$0.00 a) What is the cost?s28. Is public transportation available?29. How close is the nearest bus stop (in miles) to your site?Outside our doora) train station?4 milesb) subway station?NA30. Briefly describe the area, population density, and any safety issues regarding where the clinical center is located.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, HYPERLINK "http://www.delorme.com/cybermaps/" Delorme, HYPERLINK "http://www.expediamaps.com/DrivingDirections.asp" Microsoft, HYPERLINK "http://maps.yahoo.com/py/maps.py" Yahoo). A map can be found at HYPERLINK "http://www.performancephysicaltherapy.com" www.performancephysicaltherapy.comMeals
YesNoCommentsx32. Are meals available for students on-site? (If no, go to #33) Breakfast (if yes, indicate approximate cost) $________ Lunch (if yes, indicate approximate cost) $________ Dinner (if yes, indicate approximate cost) $________ a) Are facilities available for the storage and preparation of food?
Stipend/Scholarship
YesNoCommentsx33. Is a stipend/salary provided for students? If no, go to #36$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
YesNoCommentsx36. Is there a student dress code? If no, go to # 37.a) Specify dress code for men:professional dress, no jeansb) Specify dress code for women:professional dress, no bare midriffs, no low rise pants, no jeansx37. Do you require a case study or inservice from all students?Full time rotationsx38. Does your site have a written policy for missed days due to illness, emergency situations, other?
Other Student Information
YesNox39. 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)xDocumentation/billingxRequired assignments (eg, case study, diary/log, inservice)xLearning style inventoryxReview of goals/objectives of clinical experiencexPatient information/assignmentsxStudent expectationsxPolicies and proceduresSupplemental readingsxQuality assurancexTour of facility/departmentxReimbursement issuesOther (specify below)
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.
Index
HYPERLINK \l "SaveProtocol" Saving the Completed Form..Page 2
HYPERLINK \l "AffiliatedPTandPTAEd" Affiliated PT and PTA Educational Programs .Page 8
HYPERLINK \l "ArrangingExp" Arranging the Experience Page 15
HYPERLINK \l "RequiredBackground" Required Background......Page 16
HYPERLINK \l "RequiredMedical" Required Medical TestsPage 15
HYPERLINK \l "AvailableLearningExp" Available Learning Experiences....
HYPERLINK \l "DiagnosisLearning" Diagnosis..Page 7
HYPERLINK \l "HealthProfessionals" Health Professionals on Site....Page 8
HYPERLINK \l "SpecialtyClinics" Specialty Clinics....Page 7
HYPERLINK \l "SpecialProgramsActivitiesLearning" Special Programs/Activities/Learning Opportunities.Page 7
HYPERLINK \l "CCCEInfo" Center Coordinators of Clinical Education (CCCEs)
HYPERLINK \l "CCCEEducation" Education..Page 9
HYPERLINK \l "CCCEExp" Employment Summary.......Page 9
HYPERLINK \l "CCCEInfo" Information...Page 9
HYPERLINK \l "CCCEPreparation" Teaching Preparation...Page 10
HYPERLINK \l "CIInformation" Clinical Instructors.
HYPERLINK \l "CIInformation" InformationPage 11-12
HYPERLINK \l "CISelectionCriteria" Selection Criteria...Page 8
HYPERLINK \l "CITraining" TrainingPage 8
HYPERLINK \l "Accreditation" Clinical Site Accreditation..Page 5
HYPERLINK \l "Ownership" Clinical Site Ownership..Page 5
HYPERLINK \l "PrimaryClassification" Clinical Site Primary ClassificationPage 5
HYPERLINK \l "InformationforAcadProg" Information about the Clinical Site..Page 3
HYPERLINK \l "PrimaryPTService" Information about Physical Therapy Service
at Primary CenterPage 6
HYPERLINK \l "SatelliteSites" Satellite Site InformationPage 4
Physical Therapy Service...
HYPERLINK \l "Hours" HoursPage 6
HYPERLINK \l "NumberPatients" Number of Patients.... Page 6
HYPERLINK \l "Staffing" Staffing. Page 6
Student Information...
HYPERLINK \l "Housing" Housing..Page 16
HYPERLINK \l "Meals" Meals.Page 17
HYPERLINK \l "OtherSiteinfo" Other..Page 17
HYPERLINK \l "Stipend" Stipends..Page 17
HYPERLINK \l "Transportation" Transportation.....Page 17
PAGE
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