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CLINICAL SITE INFORMATION FORM (CSIF)

developed by

APTA Department of Physical Therapy Education

Why have a consistent Clinical Site Information Form?

The primary purpose of this form is for Physical Therapist (PT) and Physical Therapist Assistant (PTA) academic programs to collect information from clinical education sites. This information will facilitate clinical site selection, student placements, assessment of learning experiences and clinical practice opportunities available to students; and provide assistance with completion of documentation for accreditation in clinical education.

How is the form designed?

The form is divided into two sections, Information for Academic Programs - Part I (pages 3-14) and Information for Students - Part II (pages 15-17), to allow ease in retrieval of information for academic programs and for students, especially if the academic program is using a database to manage the information. Duplication of information being requested is kept to a minimum except when separation of Part I and Part II of the form would omit critical information needed by both students and the academic program. The form is also designed using a check-off format wherever possible to reduce the amount of time required for completion. This instrument can be retrieved from APTA's website at www.apta.org. Simply select the link titled “PT Education”, then the link titled “Clinical Education” and choose “Clinical Site Information Form”.

Although using a computer to complete the form is not mandatory, it is highly recommended to facilitate legible updates with minimal time investment from your facility. Additionally, the information provided will be more legible to students, academic programs, and the APTA’s Department of Physical Therapy Education. The form includes several features designed to streamline navigation, including a hyperlinked index on page 18. (Please notes that several of the hyperlinks contained in the document require your computer to have an open internet connection and a web browser)

If you prefer to complete the form manually, you may download the CSIF from APTA's website (see above). If you do not have access to a computer for this purpose, hard copies of the CSIF are available from the APTA Department of Physical Therapy Education, as well as from all PT and PTA academic programs through their Academic Coordinator of Clinical Education (ACCE).

What should I do once the form has been completed?

We encourage you to invest the time to complete the form thoroughly and accurately. Once the form has been completed, the clinical education site may e-mail the instrument to each academic program with which it affiliates, minimizing administrative time and associated costs. Please remember to make a copy of this form and retain for your records! To assist in maintaining accurate and relevant information about your physical therapy service for academic programs and students, we encourage you to update this form on an annual basis

In addition, to develop and maintain an accurate and comprehensive national database of clinical education sites, we request that a copy of the completed form be e-mailed to the Department of Physical Therapy Education at csif@apta.org or mail to:

Department of Physical Therapy Education

1111 North Fairfax Street

Alexandria, Virginia 22314

DIRECTIONS FOR COMPLETION:

If using a computer to complete this form:

When completing this form, after opening the original form, and before entering your facility’s information, save the form. The title should be your zip code, your site’s name, and the date (eg, 90210BevHillsRehab10-26-99. Please note that the date must be set apart with dashes; if slashes are used, the computer will unsuccessfully search for a directory and return an error message). Saving the document will preserve the original copy on the disk or hard drive, allowing for you to easily update your information. When completing, use the tab key or arrow keys to move to the desired blank space (the form is comprised of a series of tables to enable use of the tab key for easier data entry). Enter relevant information only in blank spaces as appropriate to your clinical site.

What should I do if my physical therapy service is associated with multiple satellite sites that also provide clinical learning experiences?

If your physical therapy service is associated with multiple satellite sites (for example, corporate hospital mergers) that offer clinical learning experiences, such as an acute care hospital that also provides clinical rotations at associated sports medicine and long-term care facilities, you will need to complete pages 3 and 4. On page 3, provide the primary clinical site for the clinical experience. On page 4, indicate other clinical sites or satellites associated with the primary clinical site. Please note that if the individual facility information varies with each satellite site that offers a clinical experience, it will be necessary to duplicate a blank CSIF and complete the form for each satellite site that offers different clinical learning experiences.

What should I do if specific items are not applicable to my clinical site or I need to further clarify a response?

If specific items on the form do not apply to your clinical education site at the time you are completing the form, please leave the item blank. Opportunities to provide comments have been made available throughout the form.

CLINICAL SITE INFORMATION FORM

I. Information About the Clinical Site

Date (3/05 )

Person Completing Questionnaire

Laurie Chocklett

E-mail address of person completing questionnaire

lac2p@virginia.edu

Name of Clinical Center

University of Virginia Health System - Acute Care

Street Address

Neuroscience Center 6 West Hospital East Box 801437

City

Charlottesville

State

Zip

22908

Facility Phone

(434) 924-0000 or (434)982-3500

Ext.

1760 (Laurie Chocklett)

PT Department Phone

(434) 924-5620 (voice mail)

Ext.

PT Department Fax

(434) 982-4058 (6W)

PT Department E-mail

lac2p@virginia.edu

Web Address

http://www.healthsystem.virginia.edu/internet/physicaltherapy/

Director of Physical Therapy

Lynn Dougherty (PT/OT/SLP Manager)

Patrick Hennelly (PT/OT/SLP Coordinator)

Director of Physical Therapy E-mail

mld5k@virginia.edu

pth3x@virginia.edu

Center Coordinator of Clinical Education (CCCE) /

Contact Person

Laurie Chocklett

CCCE / Contact Person Phone

(434) 924-5620 / (434) 924-0000 or 982-3500 ext 1760

CCCE / Contact Person E-mail

lac2p@virginia.edu

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			Zip
Facility Phone
PT Department Phone
Fax Number	Facility E-mail
Director of Physical Therapy		E-mail
Center Coordinator of Clinical Education/contact (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
Center Coordinator of Clinical Education/contact (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
Center Coordinator of Clinical Education/contact (CCCE)			E-mail

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?
		JCAHO	December 2002
		CARF
		Government Agency (eg, CORF, PTIP, rehab agency, state, etc.)
		Other
		3. who or what entity owns your clinical site? ____ PT owned __x__ Hospital Owned ____ General business / corporation ___ Other (please specify)

Place the number 1next to your clinical site's primary classification- note in bold type. Next, if appropriate, mark (X) up to 4 additonal bold typed categories that describe other clinical centers associated with your primary classification. Beneath each of the 5 possible bold typed categories, mark (X) the specific learning experiences/settings that best describe that facility.

1	Acute Care/Hospital Facility		Functional Capacity Exam- FCE	x	spinal cord injury
x	university teaching hospital		industrial rehab	x	traumatic brain injury
x	pediatric		other (please specify)		other
x	cardiopulmonary		Federal/State/County Health		School/Preschool Program
x	orthopedic		Veteran’s Administration		school system
	Other Sports PT		pediatric develop. ctr.		preschool program
	Ambulatory Care/Outpatient		adult develop. ctr.		early intervention
	geriatric		other		other
	hospital satellite	x	Home Health Care		Wellness/Prevention Program
	medicine for the arts		agency		on-site fitness center
	orthopedic		contract service		other
	pain center		hospital based		Other
	pediatric		other		international clinical site
	podiatric	x	Rehab/Subacute Rehab		administration
	sports PT		inpatient		research
	other		outpatient		other
	ECF/Nursing Home/SNF		pediatric
	Ergonomics		adult
	work hardening/conditioning		geriatric

4a. Which of these best characterizes your clinic’s location? Indicate with an ‘X’.
rural		suburban		urban	x

If your clinical site provides inpatient care, what are the number of:

500	Acute beds
	ECF beds
	Long term beds
	Psych beds
	Rehab beds
	Step down beds
	Subacute/transitional care unit
	Other beds (please specify):
600	Total Number of Beds

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
Tuesday	8:00	4:30
Wednesday	8:00	4:30
Thursday	8:00	4:30
Friday	8:00	4:30
Saturday	8:00	4:30
Sunday	8:00	4:30

7. Describe the staffing pattern for your facility: Standard 8 hour dayx7 days Varied schedules_____

(Enter additional remarks in space below, including description of weekend physical therapy staffing pattern).

Five FTE's on saturday as well as on sunday

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

	Full-time budgeted	Part-time budgeted
PTs	26	9
PTAs
Aides/Techs	1

9. Estimate an average number of patients per therapist treated per day by the provider ofphysical therapy.

INPATIENT		OUTPATIENT
8-12	Individual PT	NA	Individual PT
NA	Individual PTA	NA	Individual PTA
8-12	Total PT service per day	NA	Total PT service per day

III. Available Learning Experiences

10. Please mark (X) the diagnosis related learning experiences available at your clinical site:

x	Amputations	x	Critical care/Intensive care		Neurologic conditions
x	Arthritis	x	Degenerative diseases	x	Spinal cord injury
	Athletic injuries	x	General medical conditions	x	Traumatic brain injury
x	Burns	x	General surgery/Organ Transplant	x	Other neurologic conditions
x	Cardiac conditions		Hand/Upper extremity	x	Oncologic conditions
x	Cerebral vascular accident		Industrial injuries	x	Orthopedic/Musculoskeletal
x	Chronic pain/Pain	x	ICU (Intensive Care Unit)	x	Pulmonary conditions
	Connective tissue diseases		Mental retardation	x	Wound Care
	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.

	Administration		Industrial/Ergonomic PT		Prevention/Wellness
	Aquatic therapy	x	Inservice training/Lectures	x	Pulmonary rehabilitation
	Back school		Neonatal care		Quality Assurance/CQI/TQM
	Biomechanics lab		Nursing home/ECF/SNF		Radiology
x	Cardiac rehabilitation		On the field athletic injury		Research experience
	Community/Re-entry activities	x	Orthotic/Prosthetic fabrication		Screening/Prevention
x	Critical care/Intensive care		Pain management program		Sports physical therapy
	Departmental administration	x	Pediatric-General (emphasis on):	x	Surgery (observation)
	Early intervention		Classroom consultation	x	Team meetings/Rounds
	Employee intervention		Developmental program	x	Women’s Health/OB-GYN
	Employee wellness program		Mental retardation		Work Hardening/Conditioning
	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	x	Neurology clinic	Screening clinics
Arthritis	x	Orthopedic clinic	Developmental
Feeding clinic		Pain clinic	Scoliosis
Hand clinic		Preparticipation in sports	Sports medicine clinic
Hemophilia Clinic		Prosthetic/Orthotic clinic	Other (specify below)
Industry		Seating/Mobility clinic

13. Please mark (X) all health professionals at your clinical site with whom students might observe and/or interact.

	Administrators		Health information technologists	x	Psychologists
	Alternative Therapies	x	Nurses	x	Respiratory therapists
	Athletic trainers	x	Occupational therapists		Therapeutic recreation therapists
	Audiologists	x	Physicians (list specialties)	x	Social workers
x	Dietitians	x	Physician assistants		Special education teachers
x	Enterostomal Therapist		Podiatrists		Vocational rehabilitation counselors
	Exercise physiologists	x	Prosthetists /Orthotists	x	Others (specify below) SLP

14. List all PT and PTA education programs with which you currently affiliate.

University of Delaware	Temple
Duke	Thomas Jefferson University
Marquette	Boston University
University of MD Baltimore	Marymount University
University of MD Eastern Shore	Nova Southeastern University
Medical College of Virginia	Drexel (Hahnemann) University
Old Dominion University	University of CO Health Sciences Center
Shenandoah University	University of NC – Chapel Hill
Springfield College

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

	APTA Clinical Instructor Credentialing	x	Demonstrated strength in clinical teaching
x	Career ladder opportunity		No criteria
	Certification/Training course	x	Therapist initiative/volunteer
x	Clinical competence	x	Years of experience
	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
	Academic for-credit coursework		No training
	APTA Clinical Instructor Credentialing	x	Professional continuing education (eg, chapter, CEU course)
x	Clinical center inservices		Other (please specify)
x	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: Laurie Chocklett		Length of time as the CCCE: Began 5/96
DATE: (mm/dd/yy) 03/18/05		Length of time as the CI: since 1995
PRESENT POSITION: (Title, Name of Facility) Senior Physical Therapist UVA Health System –Neuroscience Center	Mark (X) all that apply: __x__PT ____PTA ____Other, specify	Length of time in clinical practice: Since 1994
LICENSURE: (State/Numbers) VA - 2305004901 Exp 5/31/06		Credentialed Clinical Instructor: Yes______ No__x_____
Eligible for Licensure: Yes____ No____		Certified Clinical Specialist:
		Area of Clinical Specialization: SCI, stroke, other neurological processes
		Other credentials: BLS/CPR and AED instructor through the AHA

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

INSTITUTION	PERIOD OF STUDY		MAJOR	DEGREE
	FROM	TO
Medical College of Va – Va. Commonwealth University	91	94	PT	MS PT
Radford University	82	86	Health/PE	BS - Teaching K-12

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

EMPLOYER	POSITION	PERIOD OF EMPLOYMENT
EMPLOYER	POSITION	FROM	TO
UVA Health Sciences Center – Neuroscience Center	PT	7/94	present
Spectrum Therapy/Continuum Home Health PT	Per diem HHPT	1995	1996

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):

Combine Sections – Boston - 2002
SCI symposium – Richmond - 2001
SCI: Meeting the Challenges of Lifetime Care Conference – UVA, 1998, committee member and team leader
Clinical Teaching in the 90’s – VA Consortium for Clinical Education
Developmental Manual Therapy for Physical Rehabilitation for the Neurologic Patient – Sharon Weiselfish
National Supervisors Meeting for SCI – Phoenix, AZ 1997 and Miami, FL 1999
Casting inservice to Rehab physicians 1997
Spinal Cord Injury Lead PT - 1997 to present
Inservicing for UVA staff and other facilities regarding SCI - ongoing
MS in 1999:Focus on Rehabilitation - Teleconference at UVA, December 1999
Clinical Education Workshop - annually
Clinical Education Workshop
Vestibular Workshop – Oct 2001, MD
Combine Sections 2002 – Clinically Relevant Neuroplasticity: Implications for Motor Recovery and Learning
Geriatric Neurology –Carole Lewis 2004

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= 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
Stella Prevost	PT University of MD	PT	1981	24	22	Cardiopulmonary, Lung Transplant, Pulmonary rehab	L	VA
Kathleen Henahan	Russell Sage	PT	1988	17	15	General Medicine Pulmonary;Critical Care, CF	L	VA
John Zenker	Duke	PT	1988	17	16	Neuro Eval & RX; Huntington's Disease	L	VA
Melissa Fox	Old Dominion University	PT	1994	10.5	9	Neuro, ALS, TBI, Surgery, trauma; McKenzie neck and back	L	VA
Laurie Chocklett	Medical College of VA	PT	1994	11	10	Diabetes, Neuroscience, SCI – rehab, stroke	L	VA
Marc Burkard	University of CT	PT	1991	13.5	9	Orthopedics	L	VA
Mary Casey	Northeastern U.	PT	1985	20	7	Cardiopulmonary, general surgery	L	VA, MA

CLINICAL INSTRUCTOR INFORMATION (continued)

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= 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
Tom Faisant	State University of New York	PT	1975	30	25	Orthopedics, Rehab, Geriatrics, P.T. management	L	VA
Rebecca Williams	MCV -VCU	PT	1979	26	25	Rehab, esp geriatrics	L	VA
Deanna McIntire	Medical U of SC	PT	1998	7	6	Acute ortho, general medicine	L	VA
Marc Hengartner	University of Montreal	PT	1996	8	1	Pediatrics, OP orthopedics	L	VA, MI, QC
Chad Gathers	St. Francis University	PT	2001	4	3	Acute care	L	VA, NC, PA
Tad Hardee	Medical College of Virginia	PT	1981	24	22	Burn Care, Trauma, wound care, plastic and general surgery	L	VA
Gail Bodine	North-eastern U	PT	1986	19	8	Float staff	L	VA
Jocelyn Reeder	Kings College, London	PT	1983	22	21	Cardiopulmonary	L	VA , MA

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		Final experience
	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.	4	22
20. Indicate the range of weeks you will accept students for any one part-time (< 36 hrs/wk) clinical experience.	na

	PT		PTA
21. Average number of PT and PTA students affiliating per year.	10		0

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)?

We attempt to meet the needs of individual students and would do so with students with exceptional qualities. The University has a Disabilities Service group that could provide assistance. Physical disabilities would have to be considered on a case-by-case basis due to the high physical demands of the acute patient workload.

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.


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? They are standard, but certainly can be adapted for special needs.
		students prepared at different levels within the academic curriculum?
		academic program's objectives for specific learning experiences?
		students with disabilities?
x		26. 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)

X	Beginning of the clinical experience	X	At mid-clinical experience
	Daily		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

Do you require a specific student evaluation instrument other than that of the affiliating academic program? If yes, please specify: strongly recommend the CPI

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]).

UVA is divided into service centers: Musculoskeletal, Medicine, Neuroscience, Heart, Children’s Medical Center (CMC), and Surgical. Physical Therapists cover patients in all these areas. Students will be assigned to a service center, but will have the opportunity to experience other centers as requested. Pediatrics is not coordinated through the acute CCCE, but

University of Virginia Health System

hospital based

Ergonomics

CLINICAL INSTRUCTOR INFORMATION

CLINICAL INSTRUCTOR INFORMATION (continued)