-.( 6k S-~LU, bod/- c~~l&&;l, (=.a Name of Legal Contact: (for affiliation documents)

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1 Association Nationale pour /'Education Clinique en Physioth6rapie PROFESSIONAL PRACTICE SITE PROFILE PURPOSE The purpose of this profile questionnaire is to provide information on physical environment, type of clinical experience, staffing and numbers of students that may be accommodated by your facility. The information is required for site approval by the university, by students as they request their placement facilities, and for accreditation purposes. Please complete a separate profile for each site. SECTION ONE - FACILITY 1. Facility Name: 2. Facility Address: r bod/- c~~l&&;l, 6k S-~LU, 3. Facility Mailing Address: -.( L 4. - Website Address: WUd- m~dk~'&i;h0~~,-&/~\rlq/-- ~9 Pa 5. - Name of Legal Contact: (for affiliation documents) 6. - Contact info for legal contact: (Include mailing address if different from above) V 7. Name of Centre Coordinator of Clinical Education (CCCE): 8. Telephone: s/t/ a-22 /OCQ/= //50 (Area Code) (Number) (Ext.1 9. Facsirnile: 9 y 3~9->235 (Area Code) (Number) 10. CCCE m~.td&~afo~. $//la;@ SSSS. - qouv-?c- w (=.a 11. Name of Alternate Contact when CCCE unavailable: Beverley John 2 ed d 12. Type of Facility: hbspi.fn / (e.g. Hospital, Private Practice, Community Agency) 13. Is the facility accredited? 6 s r No If yes, list accrediting bodies:

2 Nafional Associafion Associafion Nafionale p 14. Does your facility carry liability insurance? wes r No ical Educafion in Physiofherapy cation Clinique en Physiofhbrapie 15. Who or what type of entity owns your facility? Pd&1'~ Z h s L 7 - d (e.g. PT owned, Hospital owned or Physician owned) 16. Does your facility endorse the CPA Position Statement on Clinical Education of Physiotherapy Students? d e s!"- No 17. Does your facility have access to on-line Continuing Education resources? Specify: MQdllqe (e.g. McMaster LibAccess, database, search engines) 18. What chartir~g rnethods are used by your facility? r Electronic h a per Details: S"" No 19. Does your facility have a specific dress code? d r"- No Specify: no gwfimes no jea,s, no shork5, no opa-be SAOCS, / 1 / /,a */c- Cops 20. Is student parking available on-site? d s f- No (cost, info) 384 's/mon)?, 21. Is accommodation available? f- Yes &o Details of contact info: I SECTION TWO - STAFFING 1. Describe your staffing complement for Physiotherapist(s)? Budgeted FTE % FTE usually filled # Employed full time # Employed part time I Physiotherapist /, 45 1 a 5 SECTION THREE - FACILI'IY HEALTH AND ADMINISTRATION REQUIREMENTS 1. Is a criminal reference check required? f- Yes NO If so, indicate the following type: Basic Vulnerable Sector How recent must the record check be? (SpeciQ): Is proof of record check required in advance? Yes r No

3 Association Nationale p oy /'Education Clinique en Physioth6rapie 2. Is mask fit testing required? I+- No If yes, is it required in advance? 4% % No 3. Does your facility require irnmunization as per the Canadian recommendation for immunization for Health Care workers? ( immuniz auide pdf) "I" No 4. Does your facility require any additional immunizations beyond dian recommendation for Health Care Workers? r Yes Describe: 5. Does the above immunization eed to be provided to your facility prior to the start of the placement? r Yes SECTION FOUR - STUDENT EXPERIENCE 1. Is travel required as part of the student's placement? Yes 1.1 yes, does the student require a vehicle? f"" Yes /' 2. Please mark (X) for all other healthcare professionals that a student may work with during a placement: Audiologist Psychometrist Psychologist Nurse Orthotist Pastoral care Pharmacist Psychiatrist )( Occupational therapist Physician -4- Social services Community support worker Vocational rehab counsellor Teacher / principal X Radiology tech Rehab tech / assistant y Recreational therapist Speech-language pathologist Other (specifyl: 3. Please mark (X) all diagnosis related learning experiences available at your clinical site: - Amputations Critical care / intensive care Neurological conditions Arthritis - Degenerative diseases Spinal cord injury Athletic injuries - General medical condition Traumatic brain injury Burns General surgery / organ transplant Other neurological condition Cardiac condition Hand 1 upper extremity Oncologic conditions C.V.A. - Industrial injuries Orthopedic 1 musculoskeletal Chronic pain / pain Intensive care unit (ICU) Pulmonary condition Connective tissue - Mental retardation Wound care Congenital I dev. Other (specify):

4 Association Nationale pour /'Education Clinique en Physioth6rapie 4. Please mark (X) all special programs/activitiesllearning opportunities available to students during clinical experiences, or as part of an independent learning study. Administration Aquatic therapy Back school Biomechanics lab Cardiac rehab Community re entry Critical care I ICU Departmental admin. Early intervention Employee wellness Group programs Home program 1 Other (specify): Industrial I ergonomic PT In-service training I lectures Neonatal care Nursing home I ECF I SNF On the field athletic injury Orthotic 1 prosthetic fabrication Pain management program Neurological Classroom consultation Work hardening 1 conditioning Musculoskeletal Pediatric - general or emphasis on: Prevention I wellness Pulmonary rehabilitation Quality assurance Radiology Research experience Screening I prevention Sports physical therapy Surgery (observation) Team meeting I rounds Mental retardation Wound care 5. Please mark (X) all Specialty Clinics available as student learning experiences Amputee clinic - Neurological clinic Screening clinics Arthritis Orthopedic clinic Developmental Feeding clinic - Pain clinic Scoliosis Hand clinic Pre-participation in sports Sports medicine clinic Hemophilia clinic Prosthetic I orthotic clinic. Seating I mobility clinic Industry Other (speciw: 6. Please mark (X) all health professionals at your clinical site with whom students might observe and/or interact. X Administrators 1 Health information technologist 1 Psychologists - Alternative Athletic trainers therapies Nurse; Occupational therapists Therapeutic Respiratory therapists recreation Audiologists Physicians (list specialties) )( Social workers Dietitians Physician assistants Special education teachers Enterostomal therapist Podiatrists Vocational rehab counsellor Exercise physiologists Prosthetists / orthotists Speech-language pathologist Other (specify): &qp;/t3 10 q ( sb

Association Nationale pour IJEducation Clinique en Physiotherapie 7. What learning opportunities are available in the primary services listed below?

5 Association Nationale pour IJEducation Clinique en Physiotherapie 7. What learning opportunities are available in the primary services listed below? Please mark (X) and describe in terms of estimated percentage of full placement potential for each of the areas and possible hours of operation that the student may be expected to work. Major (shaded) headings may be appropriate for smaller facilities, whereas a more specific breakdown rnay be appropriate for larger centres or specialized clinics. I Medical I I I Suraical I I I I I I I Rehabilitation I I I I I 1 Outpatient Orthopaedics General - rnixed I Sports Injuries I Rheumatology Amputee Program 'Y?'<.-.'.~ '.'a ' v%-' 8 " "/",. ~~@E@l~~&!~$j~i~~?&$$~~~&~f&~~~ ',A, *"A.r I Paediatrics,.,;,&gp3.'; +;k+aa5,; I?@,y.:. ' <-3'>.>.3F$X */ ',:4 $,$ 9 lz>v;~~~..fyiw$ 5$#$,~N$~+,$:<$ :,:.:.. -,,, 2f> $-, f*~,.. R. ~.,,G+,'~;.:....., Does your facility have placement objectives for each of the abo learning opportunities? & NO If so, please describe or attach:

6 National Associafion for Clinical Education in Physiotherapy Association Nationale pour IJEducation Clinique en Physiofherapie Please provide any information pamphlets or brochures regarding your clinic for distribution to TI- is form was cornpleted by: Contact (telephone): address: SSSL~OU~@ rce Thank you for completing this form. Please mail this form to: Liliane Asseraf-Pasin Director of Clinical Education McGill University School of Physical and Occupational Therapy Davis House, Room , Sir William Osler Montreal, H3G 1Y5 OR liliane.asseraf.pasin@mcgill.ca If you have any questions and/or concerns, please contact us at: Tel: (514) Fax: (515)

- rv,rc S 3~ - 3 ~ b I Facility Address: ~SI &r~nr~,i , Facility Mailing Address: 1-4 s 4 huow hr v, \\.A 5~W-v I%&G 33V-3rL

$- rv,rc S 3~ - 3 ~ b I Facility Address: ~*SI &r~nr~,i , Facility Mailing Address: 1-4 s 4 huow hr v, \\.A 5~W-v I%&G* 33V-3rL$ Sent By: ACTON SPORT PHYSO; 450 441 6749; Jun-14-07 18:46; Page 5/12." National Asroclation for Cllnlcal Educetion n Physiotherapy Association Nailonale pour 'Educatlon Cllnique en Physiothdr8pie PROFESSONAL