CLINICAL SITE INFORMATION FORM

Transcription

1 CLINICAL SITE INFORMATION FORM Initial Date 12/04/06 Person Completing CSIF Kerri Yacovelli, MSPT address of person completing CSIF Name of Clinical Center NovaCare Rehabilitation Street Address 1 Trenton Avenue, Store 8-A Revision Date 12/28/09 City Morrisville State PA Zip Facility Phone Ext. PT Department Phone Ext. PT Department Fax PT Department kyacovelli@hq.novacare.com Clinical Center Web NovaCare.com Address Director of Physical Todd Brutto, PT Director of Physical TBrutto@selectmedicalcorp.com Center Coordinator of Clinical Kerri Yacovelli, MSPT Education (CCCE) / Contact Person CCCE / Contact Person Phone CCCE / Contact Person APTA Credentialed Clinical Instructors (CI) (List name and credentials) Other Credentialed CIs (Select Medical Corporation CI Course in SERC- internal training) kyacovelli@selectmedicalcorp.com Kerri Yacovelli, MSPT (Morrisville) Eric Czerwinski, MSPT (Feasterville) Joslyn Gower, DPT (Bristol) Franklin Antosh, MPT (Scranton) Jessica Sliker, PTA (Morrisville) Michelle Friedman, DPT (Neshaminy) Jessica Barrientos, DPT (Juniata Park) Christopher Lenihan, PT (Juniata Park)

2 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 Facility Phone Ext. PT Department Phone Ext. Fax Number (215) Facility Director of Physical Todd Brutto, PT TBrutto@selectmedicalcorp.com CCCE Kerri Yacovelli, MSPT kyacovelli@selectmedicalcorp.com Name of Clinical Site NovaCare Rehabilitation- Neshaminy Street Address Roosevelt Blvd City Philadelphia State PA Zip 19116

3 Facility Phone Ext. PT Department Phone Ext. Fax Number Facility Director of Physical Michelle Friedman, DPT CCCE Kerri Yacovelli, MSPT Name of Clinical Site NovaCare Rehabilitation-Juniata Park Street Address East Erie Avenue City Philadelphia State PA Zip Facility Phone Ext. PT Department Phone Ext. Fax Number Facility Director of Physical Jessica Barrientos, DPT CCCE Kerri Yacovelli, MSPT Name of Clinical Site NovaCare Rehabilitation-Feasterville Street Address 1040 Mill Creek Drive City Feasterville State PA Zip Facility Phone Ext. PT Department Phone Ext. Fax Number Facility Director of Physical Eric Czerwinski, MSPT CCCE Kerri Yacovelli, MSPT

4 Name of Clinical Site NovaCare Rehabilitation-Rockledge Street Address 412 Huntingdon Pike City Rockledge State PA Facility Phone Ext. PT Department Phone Ext. Fax Number Facility Director of Physical Dave Miller, PT CCCE Kerri Yacovelli, MSPT Name of Clinical Site NovaCare Rehabilitation- Northeast Street Address 6595 B East Roosevelt Boulevard City Philadelphia State PA Zip Facility Phone Ext. PT Department Phone Ext. Fax Number Facility Director of Physical Mark Human, MSPT MHuman@selectmedicalcorp.com CCCE Kerri Yacovelli, MSPT kyacovelli@selectmedicalcorp.com Name of Clinical Site NovaCare Rehabilitation- Bristol Street Address 100 Green Lane, Suite 1 City Bristol State PA Zip 19007

5 Facility Phone Ext. PT Department Phone Ext. Fax Number Facility Director of Physical Edwin Crane, DPT CCCE Kerri Yacovelli, MSPT Name of Clinical Site Worknet- Langhorne, managed by NovaCare Rehabilitation Street Address 400 N Oxford Valley Road City Langhorne State PA Zip Facility Phone Ext. PT Department Phone Ext. Fax Number Facility Director of Physical Bernadette Mellon BMellon@hq.novacare.com CCCE Kerri Yacovelli, MSPT kyacovelli@selectmedicalcorp.com Name of Clinical Site NovaCare Rehabiliatation/ Cedarbrook Street Address 3201 Cheltenham Avenue, Cedarbrook Plaza, Suite 207 City Wyncote State PA Zip Facility Phone Ext. PT Department Phone Ext. Fax Number Facility Director of Physical Frank Serino FSerino@selectmedicalcorp.com CCCE Kerri Yacovelli, MSPT kyacovelli@selectmedicalcorp.com

6 Name of Clinical Site NovaCare Rehabilitation/ Scranton Street Address 555 Lachawanna Avenue City Scranton State PA Zip Facility Phone Ext. PT Department Phone Ext. Fax Number Facility Director of Physical Frank Serino, MSPT CCCE Kerri Yacovelli, MSPT Name of Clinical Site NovaCare Rehabilitation/ Plains Street Address North River Street City Plains State PA Zip Facility Phone Ext. PT Department Phone Ext. Fax Number Facility Director of Physical Frank Serino, MSPT CCCE Kerri Yacovelli, MSPT

7 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 X Industrial/Occupational School/Preschool Program Facility Health Facility 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

8 Which of the following best describes your clinical site s location? Rural Suburban Urban

9 Information About the Clinical Teaching Faculty ABBREVIATED RESUME FOR CENTER COORDINATORS OF CLINICAL EDUCATION NAME: Kerri Yacovelli, MSPT DATE: December 29, 2009 PRESENT POSITION: Staff Physical Therapist, CCCE, CI LICENSURE: (State/Numbers) PA L, DAPT APTA Credentialed CI Yes Length of time as the CCCE: 2 years Length of time as a CI: 9 years Mark (X) all that apply: PT (X) Other CI Credentialing Length of time in clinical practice: 10 years 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 Position PERIOD OF EMPLOYMENT FROM TO

10 NovaCare Rehabilitation Staff PT, CCCE,CI 11/09 present Bucks Physical 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 Morrisville CLINICAL INSTRUCTOR INFORMATION 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 Degree No. of Years of Clinical Practice No. of Years as a CI APTA Credentialed Clinical Instructor L= Licensed, Number E= Eligible T= Temporary L/E/T Number State of Licensure Kerri Yacovelli, MSPT College Misericordia 1999 MSPT 10 9 YES PT L DAPT PA Jessica Sliker, PTA, C.Ped. Neshaminy Mercer County Community College 2002 PTA 8 years 6 NO TEI PA 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 No. of Years of Clinical No. of Years as a CI APTA Credentialed Clinical Instructor L= Licensed, Number E= Eligible T= Temporary

11 Degree Practice L/E/T Number State of Licensure Michelle Friedman, DPT Drexel University 2007 DPT 4 3 NO PT PA Juniata Park 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 Degree No. of Years of Clinical Practice No. of Years as a CI APTA Credentialed Clinical Instructor L= Licensed, Number E= Eligible T= Temporary 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 PT PA Johanna Afanador, DPT Temple 2008 DPT 2 1 NO PT PA Feasterville 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 Degree No. of Years of Clinical Practice No. of Years as a CI APTA Credentialed Clinical Instructor L= Licensed, Number E= Eligible T= Temporary L/E/T Number State of Licensure Eric Czerwinski, MSPT Thomas Jefferson University 2004 MSPT 6 3 YES PT PA

12 Northeast 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 Degree No. of Years of Clinical Practice No. of Years as a CI APTA Credentialed Clinical Instructor L= Licensed, Number E= Eligible T= Temporary L/E/T Number State of Licensure Mark Human MSPT Beaver College 1996 MSPT NO PT PA Jamie Howard, DPT Drexel University 2004 DPT 5 0 NO PT PA Ali El-Kerdi, DPT Florina Gallagher, PTA University of Maryland Eastern Shore Hahnemann University 2005 DPT 5 4 NO PT PA 1991 PTA NO TE PA Mariann Smith PTA Harcum College 2001 PTA 9 7 NO TE PA Rockledge 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 Degree No. of Years of Clinical Practice No. of Years as a CI APTA Credentialed Clinical Instructor L= Licensed, Number E= Eligible T= Temporary L/E/T Number State of Licensure Dave Miller, PT Temple University St. Josephs University: MS Health Administration BA 32 7 NO PT L PA

13 Bristol 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 Degree No. of Years of Clinical Practice No. of Years as a CI APTA Credentialed Clinical Instructor L= Licensed, Number E= Eligible T= Temporary L/E/T Number State of Licensure Edwin Crane, DPT, DAC Joslyn Gower, DPT Arcadia University Arcadia University 2005 DPT 6 4 NO PT PA 2005 DPT 5 3 YES PT PA Caroline Opperman, PTA Harcum College 1997 PTA 13 3 NO TE PA Langhorne 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 Degree No. of Years of Clinical Practice No. of Years as a CI APTA Credentialed Clinical Instructor L= Licensed, Number E= Eligible T= Temporary L/E/T Number State of Licensure Walter Scarborough, PT Bernadette Mellon, PTA Arcadia University Penn State- Hazelton 1999 MSPT 11 2 NO PT L PA 1998 PTA 12 2 NO TE PA

14 Cedarbrook 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 Degree No. of Years of Clinical Practice No. of Years as a CI APTA Credentialed Clinical Instructor L= Licensed, Number E= Eligible T= Temporary L/E/T Number State of Licensure Tom Cicippio, MPT Temple University 2006 MPT 3 1 YES PT L PA Scranton 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 Degree No. of Years of Clinical Practice No. of Years as a CI APTA Credentialed Clinical Instructor L= Licensed, Number E= Eligible T= Temporary L/E/T Number State of Licensure Franklin Antosh, MPT USP 2007 MPT 2 1 YES PT L PA PA

15 Plains 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 Degree No. of Years of Clinical Practice No. of Years as a CI APTA Credentialed Clinical Instructor L= Licensed, Number E= Eligible T= Temporary L/E/T Number State of Licensure Josh Hogan, MSPT College Misericordia 1999 MSPT 10 8 Yes PT 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 X Other (not APTA) clinical instructor credentialing Credentialing Program 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

16 internal module Information About the Physical Service Number of Patients/Clients Estimate the average number of patient/client visits per day: INPATIENT OUTPATIENT Individual PT 16 Individual PT Patient/Client Lifespan and Continuum of Care 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 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 years 1 Critical care, ICU, acute years 1 SNF/ECF/sub-acute 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

17 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

18 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

19 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 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 5:00 Saturday Sunday

20 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 Days of the Week From: (a.m.) To: (p.m.) Comments Monday 7:30 7:00 Tuesday 7:30 7:00 Wednesday 7:30 7:00 Thursday 7:30 7:00 Friday 7:30 4:00 Saturday Sunday

21 Scranton Days of the Week From: (a.m.) To: (p.m.) Comments Monday 7:30 6:30 Tuesday 7:30 6:30 Wednesday 7:30 1:00 Thursday 7:30 6:30 Friday 7:30 1:00 Saturday Sunday Plains Days of the Week From: (a.m.) To: (p.m.) Comments Monday 7:30 6:30 Tuesday 7:30 6:30 Wednesday 7:30 5:30 Thursday 7:30 6:30 Friday 7:30 1:00 Saturday Sunday 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:

22 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 Full-time budgeted Part-time budgeted Current Staffing PTs 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

23 Rockledge Full-time budgeted Part-time budgeted Current Staffing PTs PTAs Aides/Techs Others: Specify Bristol Full-time budgeted Part-time budgeted Current Staffing PTs PTAs 1 1 Aides/Techs Others: Specify Feasterville Full-time budgeted Part-time budgeted Current Staffing PTs 1 1 PTAs Aides/Techs Others: Specify Langhorne Full-time budgeted Part-time budgeted Current Staffing PTs 1 1 PTAs 1 1 Aides/Techs Others: Specify

24 Cedarbrook Full-time budgeted Part-time budgeted Current Staffing PTs 4 4 PTAs 1 1 Aides/Techs Others: Specify Scranton Full-time budgeted Part-time budgeted Current Staffing PTs 1 1 PTAs Aides/Techs Others: Specify Plains Full-time budgeted Part-time budgeted Current Staffing PTs PTAs 1 1 Aides/Techs Others: Specify Information About the Clinical Education Experience

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

26 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: Nurses Social workers List: 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). X Physical Therapist First experience: Check all that apply. Half days Full days Other: (Specify) X Physical Therapist Assistant 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)

27 Specialty experience Indicate the range of weeks you will accept students for any single full-time (36 hrs/wk) clinical experience. Indicate the range of weeks you will accept students for any one parttime (< 36 hrs/wk) clinical experience. PT PTA From To From To 1/09 12/09 1/09 12/09 1/09 12/09 1/09 12/09 Morrisville Average number of PT and PTA students affiliating per year. Clarify if multiple sites. Juniata Park Average number of PT and PTA students affiliating per year. Clarify if multiple sites. Northeast Average number of PT and PTA students affiliating per year. Clarify if multiple sites. Rockledge Average number of PT and PTA students affiliating per year. Clarify if multiple sites. PT 2 1 PT 2 0 PT 3 2 PT 2 0 PTA PTA PTA PTA Bristol Average number of PT and PTA students affiliating per year. Clarify if multiple sites. PT 2 0 PTA

28 Feasterville Average number of PT and PTA students affiliating per year. Clarify if multiple sites. Langhorne Average number of PT and PTA students affiliating per year. Clarify if multiple sites. PT 2 0 PT 2 1 PTA PTA 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 # 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?

29 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 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.

30 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 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. 9. How current are student physical exam records required to be? 10. Are any other health tests or immunizations required on-site? If yes, please specify: Copy sent with student information 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

31 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?

32 31. Person to contact to obtain/confirm housing: Name: Address: City: State: Zip: Phone: 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.

33 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

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