CLINICAL SITE INFORMATION FORM (CSIF) - University of...

CLINICAL SITE INFORMATION FORM

Initial Date 12/04/06

Revision Date 12/28/09 Person Completing CSIF Kerri Yacovelli, MSPT

E-mail address of person completing CSIF

[email protected]

Name of Clinical Center NovaCare Rehabilitation

Street Address 1 Trenton Avenue, Store 8-A

City Morrisville State

PA Zip 19067

Facility Phone 215-295-4538 Ext.

PT Department Phone 215-295-4538 Ext.

PT Department Fax 215-295-3895

PT Department E-mail [email protected]

Clinical Center Web Address

NovaCare.com

Director of Physical Therapy

Todd Brutto, PT

Director of Physical Therapy E-mail [email protected]

Center Coordinator of Clinical Education (CCCE) / Contact Person

Kerri Yacovelli, MSPT

CCCE / Contact Person Phone 215-295-4538

CCCE / Contact Person E-mail [email protected]

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

Kerri Yacovelli, MSPT (Morrisville) Eric Czerwinski, MSPT (Feasterville) Joslyn Gower, DPT (Bristol) Franklin Antosh, MPT (Scranton)

Other Credentialed CIs (Select Medical Corporation CI Course in SERC- internal training)

Jessica Sliker, PTA (Morrisville) Michelle Friedman, DPT (Neshaminy) Jessica Barrientos, DPT (Juniata Park) Christopher Lenihan, PT (Juniata Park)

Johanna Afanador, DPT (Juniata Park) Mark Human, MSPT (Northeast) Jamie Howard, DPT (Northeast) Ali El-Kerdi, DPT (Northeast) Forina Gallagher, PTA (Northeast) Mariann Harris, PTA (Northeast) Dave Miller, PT (Rockledge) Edwin Crane, DPT (Bristol) Caroline Opperman, PTA (Bristol) Walter Scarborough, PT (Langhorne) Bernadette Mellon, PTA (Langhorne)

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

Proof of student health clearance Criminal background check First Aid and CPR HIPAA education OSHA education

Information About Multi-Center Facilities

Name of Clinical Site NovaCare Rehabilitation- Morrisville

Street Address 1 E Trenton Ave Store 8A

City Morrisville State PA Zip 19067



Fax Number (215) 295-3895 Facility E-mail


Todd Brutto, PT

E-mail [email protected]

CCCE

Kerri Yacovelli, MSPT E-mail [email protected]

Name of Clinical Site NovaCare Rehabilitation- Neshaminy

Street Address 11596 Roosevelt Blvd

City Philadelphia State PA Zip 19116

mailto:[email protected]




Fax Number 215-969-2681 Facility E-mail


Michelle Friedman, DPT E-mail [email protected]

CCCE


Name of Clinical Site NovaCare Rehabilitation-Juniata Park

Street Address 1107-11 East Erie Avenue

City Philadelphia State PA Zip 19124





Jessica Barrientos, DPT


CCCE


Name of Clinical Site NovaCare Rehabilitation-Feasterville

Street Address 1040 Mill Creek Drive

City Feasterville State PA Zip 19053





Eric Czerwinski, MSPT


CCCE








Name of Clinical Site NovaCare Rehabilitation-Rockledge

Street Address 412 Huntingdon Pike

City Rockledge State PA

19046





Dave Miller, PT


CCCE


Name of Clinical Site NovaCare Rehabilitation- Northeast

Street Address 6595 B East Roosevelt Boulevard

City Philadelphia State PA

Zip

19149





Mark Human, MSPT


CCCE


Name of Clinical Site NovaCare Rehabilitation- Bristol

Street Address 100 Green Lane, Suite 1

City Bristol State PA

Zip

19007







Fax Number 215-215-826-0285 Facility E-mail


Edwin Crane, DPT


CCCE


Name of Clinical Site Worknet- Langhorne, managed by NovaCare Rehabilitation

Street Address 400 N Oxford Valley Road

City Langhorne State PA

Zip

19047

Facility Phone 215- 943-9000 Ext.




Bernadette Mellon


CCCE


Name of Clinical Site NovaCare Rehabiliatation/ Cedarbrook

Street Address 3201 Cheltenham Avenue, Cedarbrook Plaza, Suite 207

City Wyncote State PA

Zip

19095





Frank Serino


CCCE Kerri Yacovelli, MSPT E-mail [email protected]







Name of Clinical Site NovaCare Rehabilitation/ Scranton

Street Address 555 Lachawanna Avenue

City Scranton State PA

Zip

18503





Frank Serino, MSPT


CCCE


Name of Clinical Site NovaCare Rehabilitation/ Plains

Street Address 40667 North River Street

City Plains State PA

Zip

18705





Frank Serino, MSPT


CCCE






Clinical Site Accreditation/Ownership Yes No Date of Last

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

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

JCAHO

CARF

Government Agency (eg, CORF, PTIP, rehab agency, state, etc.)

Other

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

Corporate/Privately Owned

Clinical Site Primary Classification To complete this section, please: A. Place the number 1 (1) beside the category that best describes how your facility functions the majority (> 50%) of the time. Click on the drop down box to the left

to select the number 1. B. Next, if appropriate, check (?) up to four additional categories that describe the other clinical centers associated with your facility.

Acute Care/Inpatient Hospital

Facility X Industrial/Occupational

Health Facility School/Preschool Program

1 Ambulatory Care/Outpatient Multiple Level Medical

Center X Wellness/Prevention/Fitness

Program ECF/Nursing Home/SNF Private Practice Other: Specify

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

Rehabilitation

Clinical Site Location

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

Rural Suburban Urban

Information About the Clinical Teaching Faculty

ABBREVIATED RESUME FOR CENTER COORDINATORS OF CLINICAL EDUCATION

NAME: Kerri Yacovelli, MSPT

Length of time as the CCCE: 2 years

DATE: December 29, 2009

Length of time as a CI: 9 years

PRESENT POSITION: Staff Physical Therapist, CCCE, CI

Mark (X) all that apply: PT (X)

Length of time in clinical practice: 10 years

LICENSURE: (State/Numbers) PA-012699-L, DAPT-001866

APTA Credentialed CI Yes

Other CI Credentialing

Eligible for Licensure: Certified Clinical Specialist:

Area of Clinical Specialization:

Other credentials:

INSTITUTION

PERIOD OF STUDY

MAJOR DEGREE

FROM TO

College Misericordia 9/94 5/99 Entry level PT MSPT

. SUMMARY OF PRIMARY EMPLOYMENT

PERIOD OF EMPLOYMENT

Position

FROM TO

NovaCare Rehabilitation Staff PT, CCCE,CI 11/09 present

Bucks Physical Therapy Staff PT, CI 01/09 11/09

NovaCare Rehabiliation Staff PT, CCCE, CI 03/02 01/09

The Rehab Place Staff PT 07/99 03/02

CONTINUING PROFESSIONAL PREPARATION RELATED DIRECTLY TO CLINICAL TEACHING RESPONSIBILITIES

Course Provider/Location Date

APTA Credentialing 2008

CLINICAL INSTRUCTOR INFORMATION

Morrisville

L= Licensed, Number E= Eligible T= Temporary

Name followed by credentials (eg, Joe Therapist, DPT, OCS

Jane Assistant, PTA, BS)

PT/PTA Program

from Which CI Graduated

Year of Graduation

Highest Earned Physical Therapy Degree

No. of

Years of Clinical Practice

No. of Years

as a CI

APTA Credentialed Clinical Instructor

L/E/T Number

State of Licensure

Kerri Yacovelli, MSPT College Misericordia

1999 MSPT 10 9 YES PT-012699-L DAPT-001866

PA

Jessica Sliker, PTA, C.Ped. Mercer County Community College

2002 PTA 8 years 6 NO TEI002152

PA

Neshaminy



PT/PTA Program


Year of Graduation

Highest Earned Physical

No. of

Years of Clinical

No. of Years

as a CI



Therapy Degree

Practice

L/E/T Number

State of Licensure

Michelle Friedman, DPT Drexel University 2007 DPT 4 3 NO PT018925 PA

Juniata Park




PT/PTA Program


Year of Graduation


No. of


No. of Years

as a CI


L/E/T Number

State of Licensure

Jessica Barrientos, DPT Temple University 1999 DPT 10 9 NO PT012989L PA

Christopher Lenihan, PT University of Salford (England)

2003 BA 7 4 NO PT019874 PA

Johanna Afanador, DPT Temple 2008 DPT 2 1 NO PT019624 PA

Feasterville




PT/PTA Program


Year of Graduation


No. of


No. of Years

as a CI


L/E/T Number

State of Licensure

Eric Czerwinski, MSPT Thomas Jefferson University

2004 MSPT 6 3 YES PT017231 PA

Northeast




PT/PTA Program


Year of Graduation


No. of


No. of Years

as a CI


L/E/T Number

State of Licensure

Mark Human MSPT Beaver College 1996 MSPT 14 13 NO PT010120 PA

Jamie Howard, DPT Drexel University 2004 DPT 5 0 NO PT017054 PA

Ali El-Kerdi, DPT University of Maryland Eastern Shore

2005 DPT 5 4 NO PT018723 PA

Florina Gallagher, PTA Hahnemann University

1991 PTA 19 13 NO TE1000686 PA

Mariann Smith PTA Harcum College 2001 PTA 9 7 NO TE006617 PA

Rockledge




PT/PTA Program


Year of Graduation


No. of


No. of Years

as a CI


L/E/T Number

State of Licensure

Dave Miller, PT Temple University St. Josephs University: MS Health Administration

1978 2002

BA 32 7 NO PT 003544-L PA

Bristol




PT/PTA Program


Year of Graduation


No. of


No. of Years

as a CI


L/E/T Number

State of Licensure

Edwin Crane, DPT, DAC Arcadia University

2005 DPT 6 4 NO PT 017641 PA

Joslyn Gower, DPT Arcadia University

2005 DPT 5 3 YES PT 017509 PA

Caroline Opperman, PTA Harcum College 1997 PTA 13 3 NO TE1000821 PA

Langhorne




PT/PTA Program


Year of Graduation


No. of


No. of Years

as a CI


L/E/T Number

State of Licensure

Walter Scarborough, PT Arcadia University

1999 MSPT 11 2 NO PT 013152L PA

Bernadette Mellon, PTA Penn State- Hazelton

1998 PTA 12 2 NO TE1001457 PA

Cedarbrook




PT/PTA Program


Year of Graduation


No. of


No. of Years

as a CI


L/E/T Number

State of Licensure

Tom Cicippio, MPT Temple University

2006 MPT 3 1 YES PT-018352-L PA

Scranton




PT/PTA Program


Year of Graduation


No. of


No. of Years

as a CI


L/E/T Number

State of Licensure

Franklin Antosh, MPT USP 2007 MPT 2 1 YES PT-018877-L PA

PA

Plains




PT/PTA Program


Year of Graduation


No. of


No. of Years

as a CI


L/E/T Number

State of Licensure

Josh Hogan, MSPT College Misericordia

1999 MSPT 10 8 Yes PT-012834-L PA

Clinical Instructors What criteria do you use to select clinical instructors? APTA Clinical Instructor Credentialing No criteria Career ladder opportunity Other (not APTA) clinical instructor credentialing Certification/training course X Therapist initiative/volunteer X Clinical competence X Years of experience Delegated in job description X Other (please specify): X Demonstrated strength in clinical

teaching “Clinical Instructor Training: Planning and

Preparing for Students” internal module

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

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

Academic for-credit coursework No training

X APTA Clinical Instructor Education and Credentialing Program

X Other (not APTA) clinical instructor credentialing program

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

Continuing education by academic program

X Other (please specify): “Clinical Instructor Training: Planning and Preparing for Students”

internal module

Information About the Physical Therapy Service

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

INPATIENT OUTPATIENT Individual PT 16 Individual PT

Student PT varies Student PT Individual PTA 16 Individual PTA Student PTA varies Student PTA PT/PTA Team PT/PTA Team Total patient/client visits per day Total patient/client visits per day

Patient/Client Lifespan and Continuum of Care Indicate the frequency of time typically spent with patients/clients in each of the categories using the key below: 1=(0%) 2=(1-25%) 3=(26-50%) 4=(51-75%) 5=(76-100%) Rating Patient Lifespan Rating Continuum of Care

2 0-12 years 1 Critical care, ICU, acute 2 13-21 years 1 SNF/ECF/sub-acute 4 22-65 years 2 Rehabilitation 3 Over 65 years 4 Ambulatory/outpatient 1 Home health/hospice 4 Wellness/fitness/industry

Patient/Client Diagnoses 1. Indicate the frequency of time typically spent with patients/clients in the primary diagnostic groups (bolded) using the key below:

1 = (0%) 2 = (1-25%) 3 = (26-50%) 4 = (51-75%) 5 = (76-100%)

(1-5) Musculoskeletal

3 Acute injury 3 Muscle disease/dysfunction 2 Amputation 3 Musculoskeletal degenerative disease 3 Arthritis 4 Orthopedic surgery 3 Bone disease/dysfunction Other: (Specify) 3 Connective tissue disease/dysfunction

(1-5) Neuro-muscular

2 Brain injury 2 Peripheral nerve injury 2 Cerebral vascular accident 2 Spinal cord injury 3 Chronic pain 2 Vestibular disorder 2 Congenital/developmental Other: (Specify) 2 Neuromuscular degenerative disease

(1-5) Cardiovascular-pulmonary

2 Cardiac dysfunction/disease 1 Peripheral vascular dysfunction/disease 2 Fitness Other: (Specify) 2 Lymphedema 2 Pulmonary dysfunction/disease

(1-5) Integumentary

1 Burns Other: (Specify) 2 Open wounds 2 Scar formation

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

2 Cognitive impairment 2 Organ transplant 2 General medical conditions 2 Wellness/Prevention 2 General surgery Other: (Specify) 2 Oncologic conditions

Hours of Operation

Facilities with multiple sites with different hours must complete this section for each clinical center. Morrisville

Days of the Week From: (a.m.) To: (p.m.) Comments Monday 8:00 7:00 Tuesday 8:00 7:00 Wednesday 8:00 7:00 Thursday 8:00 7:00 Friday 8:00 4:00 Saturday Sunday

Neshaminy Days of the Week From: (a.m.) To: (p.m.) Comments

Monday 8:00 7:00 Tuesday 8:00 7:00 Wednesday 8:00 5:00 Thursday 8:00 7:00 Friday 8:00 4:00 Saturday Sunday Juniata Park

Days of the Week From: (a.m.) To: (p.m.) Comments Monday 8:00 7:00 Tuesday 8:00 7:00 Wednesday 8:00 7:00 Thursday 8:00 7:00 Friday 8:00 2:00

Saturday Sunday Northeast

Days of the Week From: (a.m.) To: (p.m.) Comments Monday 7:30 7:30 Tuesday 7:30 7:30 Wednesday 7:30 7:30 Thursday 7:30 7:30 Friday 8:00 5:00 Saturday Sunday Rockledge

Days of the Week From: (a.m.) To: (p.m.) Comments Monday 8:00 7:00 Tuesday 9:00 7:00 Wednesday 8:00 1:00 Thursday 9:00 7:00 Friday 8:00 2:00 Saturday Sunday Bristol


Langhorne

Days of the Week From: (a.m.) To: (p.m.) Comments Monday 8:00 5:00 Tuesday 8:00 5:00 Wednesday 8:00 5:00 Thursday 8:00 5:00 Friday 8:00 5:00 Saturday Sunday Feasterville

Days of the Week From: (a.m.) To: (p.m.) Comments Monday 8:00 7:00 Tuesday Wednesday 8:00 7:00 Thursday 8:00 7:00 Friday Saturday Sunday

Cedarbrook


Scranton


Plains


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

Varied schedules

Describe the schedule(s) the student is expected to follow during the clinical experience: The student follows the CI's schedule.

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

Morrisville

Full-time budgeted Part-time budgeted Current Staffing

PTs 1 1 PTAs 1 1 Aides/Techs Others: Specify

Neshaminy Full-time budgeted Part-time budgeted Current Staffing

PTs 2 2 PTAs 1 1 Aides/Techs Others: Specify OT

Juniata Park


PTs 3 0 3 PTAs 1 1 Aides/Techs Others: Specify

Northeast Full-time budgeted Part-time budgeted Current Staffing

PTs 4 4 PTAs 3 3 Aides/Techs Others: Specify OT

Rockledge Full-time budgeted Part-time budgeted Current Staffing

PTs 1 1 2 PTAs Aides/Techs Others: Specify

Bristol Full-time budgeted Part-time budgeted Current Staffing

PTs 3 1 4 PTAs 1 1 Aides/Techs Others: Specify

Feasterville


PTs 1 1 PTAs Aides/Techs Others: Specify

Langhorne



Cedarbrook



Scranton


PTs 1 1 PTAs Aides/Techs Others: Specify

Plains


PTs 1 1 1.5 PTAs 1 1 Aides/Techs Others: Specify

Information About the Clinical Education Experience

Special Programs/Activities/Learning Opportunities

X Administration X Industrial/ergonomic PT X Quality Assurance/CQI/TQM

X Aquatic therapy X Inservice training/lectures Radiology X Athletic venue coverage Neonatal care Research experience X Back school Nursing home/ECF/SNF Screening/prevention X Biomechanics lab Orthotic/Prosthetic fabrication X Sports physical therapy X Cardiac rehabilitation X Pain management program X Surgery (observation) Community/re-entry

activities Pediatric-general (emphasis on): X Team meetings/rounds

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

Hardening/conditioning Employee intervention X Musculoskeletal Wound care Employee wellness program X Neurological Other (specify below)

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

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

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

Neurology clinic

Health and Educational Providers at the Clinical Site Please mark (X) all health care and educational providers at your clinical site students typically observe and/or with whom they interact. X Administrators Massage therapists Speech/language

pathologists Alternative therapies:

List: Nurses Social workers

Athletic trainers X Occupational therapists Special education teachers Audiologists Physicians (list specialties) X Students from other

disciplines Dietitians Physician assistants X Students from other physical

therapy education programs Enterostomal /wound

specialists Podiatrists Therapeutic recreation

therapists Exercise physiologists Prosthetists /orthotists Vocational rehabilitation

counselors Fitness professionals Psychologists

Health information

technologists Respiratory therapists

Availability of the Clinical Education Experience

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

Physical Therapist Physical Therapist Assistant X First experience: Check all that apply.

Half days Full days Other: (Specify)

X First experience: Check all that apply. Half days Full days Other: (Specify)

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

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

X Final experience X Final experience Internship (6 months or longer)

Specialty experience

PT PTA From To From To

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

1/09 12/09 1/09 12/09

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

1/09 12/09 1/09 12/09

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

2 1

Juniata Park

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

2 0

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

3 2

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

2 0

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

2 0

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

2 0

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

2 1

Yes No Comments

X Is your clinical site willing to offer reasonable accommodations for students under ADA?

What is the procedure for managing students whose performance is below expectations or unsafe? Contact Clinical Coordinator of school, and discuss issues/policies.

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.

Clinical Site’s Learning Objectives and Assessment

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

If no, go to # 3.

2. Do these objectives accommodate: X •1 The student’s objectives? X •2 Students prepared at different levels within the academic curriculum? X •3 The academic program's objectives for specific learning experiences? X •4 Students with disabilities?

X 3. Are all professional staff members who provide physical therapy services acquainted with the clinical site's learning objectives?

When do the CCCE and/or CI typically discuss the clinical site's learning objectives with students? (Mark (X) all that apply)

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

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 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

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]). Our sites have recently began documentation on Therapy Source. All documentation is now performed on laptops. Each clinician has their own laptop. Students will be sharing those of their CI's. At NovaCare we understand that each clinical affiliation is different. We discuss goals and expectations of each student upon arrival. We modify as needed throughout their affiliations.

Part II. Information for Students Arranging the Experience

Yes No Comments

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?

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

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

X 6. Is a Rubella Titer Test or immunization required?

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

If yes, please specify:

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

Copy sent with student information

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

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

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

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

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

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

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

X 16. Is emergency health care available for students?

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

X 17. Is other non-emergency medical care available to students?

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

Yes No Comments

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

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

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

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

X 21. Is a child abuse clearance required?

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

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

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

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

Housing

Yes No Comments

X 26. Is housing provided for male students? (If no, go to #32)

X 27. 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: Zip:

Phone: E-mail:

Yes No

Comments Co

32. If housing is not provided for either gender: a) Is there a contact person for information on housing in

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

Please contact center. At times, we can help with housing.

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

Transportation

Yes No Comments

X 33. Will a student need a car to complete the clinical experience? X 34. Is parking available at the clinical center? No cost a) What is the cost for parking?

X 35. Is public transportation available?

36. How close is the nearest transportation (in miles) to your site? Varies on location of center

a) Train station? miles b) Subway station? miles c) Bus station? miles d) Airport? miles

37. Briefly describe the area, population density, and any safety issues regarding where the clinical center is located.

Mostly middle-class with high density.

38. Please enclose a map of your facility, specifically the location of the department and parking. Travel directions can be obtained from several travel directories on the internet. (eg, Delorme, Microsoft, Yahoo, Mapquest).

Meals

Yes No Comments

X 39. Are meals available for students on-site? (If no, go to #40) Breakfast (if yes, indicate

approximate cost)

Lunch (if yes, indicate approximate cost)

Dinner (if yes, indicate approximate cost)

X 40. Are facilities available for the storage and preparation of food? Stipend/Scholarship

Yes No Comments

X 41. Is a stipend/salary provided for students? If no, go to #43.

a) How much is the stipend/salary? ($ / week)

42. Is this stipend/salary in lieu of meals or housing?

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

Special Information

Yes No Comments X 44. Is there a facility/student dress code? If no, go to # 45.

If yes, please describe or attach.

a) Specify dress code for men:

Dress pants with polo shirt and/or button down shirt, clean closed back/toe shoes

b) Specify dress code for women:

Dress pants with polo shirt and/or button down shirt, clean closed back/toe shoes

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

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

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

X 48. Will the student have access to the Internet at the clinical site? Limited to educational sites

Other Student Information

Yes No

X 49. Do you provide the student with an on-site orientation to your clinical site? (mark X below)

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

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

CLINICAL SITE INFORMATION FORM (CSIF) - University of...

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