Clinical Site Information Form(Csif)

CLINICAL SITE INFORMATION FORM(CSIF)

APTA Department of Physical Therapy Education

Revised January 2006

INTRODUCTION:

The primary purpose of the Clinical Site Information Form (CSIF) is for Physical Therapist (PT) and Physical Therapist Assistant (PTA) academic programs to collect information from clinical education sites to:

• Facilitate clinical site selection,
• Assist in student placements,
• Assess the learning experiences and clinical practice opportunities available to students; and
• Provide assistance with completion of documentation required for accreditation.

The CSIF is divided into two sections:

• Part I: Information for Academic Programs (pages 4-16)
• Information About the Clinical Site (pages 4-6)
• Information About the Clinical Teaching Faculty (pages 7-10)
• Information About the Physical Therapy Service (pages 10-12)
• Information About the Clinical Education Experience (pages 13-16)
• Part II: Information for Students (pages 17-20)

Duplication of requested information is kept to a minimum except when separation of Part I and Part II of the CSIF would omit critical information needed by both students and the academic program. The CSIF is also designed using a check-off format wherever possible to reduce the amount of time required for completion.

Department of Physical Therapy Education

1111 North Fairfax Street

Alexandria, Virginia22314

DIRECTIONS FOR COMPLETION:

To complete the CSIF go to APTA's website at under “Education Programs,” click on “Clinical” and choose “Clinical Site Information Form.” This document is available as a Word document.

1. Save the CSIF on your computer before entering your facility’s information.The title should be the clinical site’s zip code, clinical site’s name, and the date (eg, 90210BevHillsRehab10-26-2005). Using this format for titling the document allows the users to quickly identify the facility and most recent version of the CSIF from a folder. Saving the document will preserve the original copy on the disk or hard drive, allowing for ease in updating the document as changes in the clinical site information occurs.
2. Complete the CSIF thoroughly and accurately. 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 quicker data entry. Use the Comment section to provide addition information as needed. If you need additional space please attach a separate sheet of paper.
3. Save the completed CSIF.
4. E-mail the completed CSIF to each academic program with whom the clinic affiliates (accepts students).
5. In addition, to develop and maintain an accurate and comprehensive national database of clinical education sites, e-mail a copy of the completed CSIF to the Department of Physical Therapy Education at .
6. Update the CSIF on an annual basis to assist in maintaining accurate and relevant information about your physical therapy service for academic programs, students, and the national database.

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 that offer a variety of clinical learning experiences, such as an acute care hospital that also provides clinical rotations at associated sports medicine and long-term care facilities, provide information regarding the primary clinical site for the clinical experience on page 4. Complete page 4, to provide essential information on all additional clinical sites or satellites associated with the primary clinical site. Please note that if the satellite site(s) offering a clinical experience differs from the primary clinical site, a separate CSIF must be completed for each satellite site. Additionally, if any of the satellite sites have a different CCCE, an abbreviated resume must be completed for each individual serving as CCCE.

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 CSIF do not apply to your clinical education site at the time you are completing the form, please leave the item(s) blank.Provide additional information and/or comments in the Comment box associated with the item.

Table of Contents

Introduction and Instructions ...... 1-2

Clinical Site Information
Primary Site...... 4
Multi-Center Facilities...... 5

Accreditation/Ownership...... 6

Primary Classification...... 6

Location...... 6

Clinical Teaching Faculty

Center Coordinators of Clinical Education (CCCEs) – Abbreviated Resume...... 6

Education...... 7

Employment...... 7

Teaching Preparation...... 8

Clinical Instructor

Information...... 9

Selection Criteria...... 10

Training...... 10

Physical Therapy Service

Number of Inpatient Beds...... 10

Number of Patients/Clients...... 10

Patient/Client Lifespan and Continuum of Care...... 11

Patient/Client Diagnoses...... 11

Hours of Operation...... 12

Staffing...... 12

Clinical Education Experience

Special Programs/Activities/Learning Opportunities...... 13

Specialty Clinics...... 13

Health and Educational Providers at the Clinical Site...... 14

Affiliated PT and PTA Education Programs...... 14

Availability of the Clinical Education Experience...... 15

Learning Objectives and Assessments...... 16

Student Information

Arranging the Experience...... 17
Housing...... 17-18

Transportation...... 19

Meals...... 19

Stipend/Scholarship...... 20

Special Information...... 20

Other...... 20

1

CLINICAL SITE INFORMATION FORM

/ Initial Date 03/18/03
Revision Date 3/27/09
Person Completing CSIF / Marty Ebert PT, CCE
E-mail address of person completing CSIF /

Name of Clinical Center / Yakima Regional Medical and Cardiac Center
Street Address / 110 South 9th Avenue
City / Yakima / State / WA / Zip / 98902
Facility Phone / (509)575-5000 / Ext.
PT Department Phone / (509)575-5054 / Ext.
PT Department Fax / (509)573-3542
PT Department E-mail /

Clinical Center Web Address /
Director of Physical Therapy / Angie Meloy PT and Karen Rice PT
Director of Physical Therapy E-mail /

Center Coordinator of Clinical Education (CCCE) / Contact Person / Marty Ebert PT
CCCE / Contact Person Phone / (509)575-5054
CCCE / Contact Person E-mail /

APTA Credentialed Clinical Instructors (CI)
(List name and credentials) / Marty Ebert - Mentoring future clinicians
Other Credentialed CIs
(List name and credentials)
Indicate which of the following are required by your facility prior to the clinical education experience: / Proof of student health clearance
Criminal background check
Child clearance
Drug screening
First Aid and CPR
HIPAA education
OSHA education
Other: Please list TB and MMR testing

1

Information About Multi-Center Facilities

If your health care system or practice has multiple sites or clinical centers, complete the following table(s) for each of the sites. Where information is the same as the primary clinical site, indicate “SAME.” If more than three sites, copy, and paste additional sections of this table before entering the requested information. Note that you must complete an abbreviated resume for each CCCE.

Name of Clinical Site / Yakima Regional Outpatient Therapies
Address / 209 South 12th Avenue
City / Yakima / State / WA / Zip / 98902
Facility Phone / (509) 575-5068 / Ext.
PT Department Phone / (509) 575-5068 / Ext.
Fax Number / (509) 577-4604 / Facility E-mail /

Director of Physical Therapy / Angie Meloy and Karen Rice / E-mail /

CCCE / Marty Ebert PT / 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
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
CCCE / E-mail

1

Clinical Site Accreditation/Ownership

Yes / No / Date of Last Accreditation/Certification
Is your clinical site certified/ accredited? If no, go to #3.
If yes, has your clinical site been certified/accredited by:
JCAHO / 9/08
CARF / 9/04, 9/07
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
Government Agency
Hospital/Medical Center Owned
Nonprofit Agency
Physician/Physician Group Owned
PT Owned
PT/PTA Owned
Other (please specify)

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.

12345 / Acute Care/Inpatient Hospital Facility / 12345 / Industrial/Occupational Health Facility / 12345 / School/Preschool Program
12345 / Ambulatory Care/Outpatient / 12345 / Multiple Level Medical Center / 12345 / Wellness/Prevention/Fitness Program
12345 / ECF/Nursing Home/SNF / 12345 / Private Practice / 12345 / Other: Specify
12345 / Federal/State/County Health / 12345 / Rehabilitation/Sub-acute Rehabilitation

Clinical Site Location

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

1

Information About the Clinical Teaching Faculty

ABBREVIATED RESUME FOR CENTER COORDINATORS OF CLINICAL EDUCATION

Please update as each new CCCE assumes this position.

NAME: Marty Ebert PT / Length of time as the CCCE: 7 years
DATE: (mm/dd/yy) 03/27/09 / Length of time as a CI: 40 years
PRESENT POSITION: Staff PT, CCE
Yakima Regional Medical and Cardiac Center
(Title, Name of Facility) / Mark (X) all that apply:
PT
PTA
Other, specify / Length of time in clinical practice: 40 yrs
LICENSURE: (State/Numbers)
WA/0828 WI/974-024 / APTA Credentialed CI
Yes No / Other CI Credentialing
Yes No
Eligible for Licensure: Yes No / Certified Clinical Specialist: Yes No
Area of Clinical Specialization:
Other credentials:

1

INSTITUTION / PERIOD OF STUDY / MAJOR / DEGREE
FROM / TO
University of Wisconsin-Madison / 9/66 / 8/69 / Physical Therapy / BS, PT
University of Wisconsin-Platteville / 1/66 / 6/66 / Pre-PT
University of Wisconsin-Lacrosse / 9/65 / 12/65 / Physical Ed
University of Wisconsin-Platteville / 9/64 / 6/65 / Physical Ed

SUMMARY OF COLLEGE AND UNIVERSITY EDUCATION (Start with most current): Tab to add additional rows.

SUMMARY OF PRIMARY EMPLOYMENT(For current and previous four positions since graduation from college; start with most current): Tab to add additional rows.

EMPLOYER / POSITION / PERIOD OF EMPLOYMENT
FROM / TO
Yakima Regional / Staff PT, PT Supervisor 84-89 / 4/73 / Present
University Hospitals – Madison, WI / Staff PT / 9/69 / 4/73

1

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 three (3) years): Tab to add additional rows.

Course / Provider/Location / Date
Geriatric Orthopedics / Rehab Seminars
Seattle, WA / 3/31/06
Mentoring Future Clinicians / WSU/Eastern WA Univ / 2/14/06
Current trends in Stroke Rehab / Tri Cities Rehab / 3/14/09
TBI Seminar / Harborveiw Med. Ctr
Seattle, WA / 4/07

1

CLINICAL INSTRUCTOR INFORMATION

Provide the following information on all PTs or PTAs employed at your clinical site who are CIs. For clinical sites with multiple locations, use one form for each location and identify the location here. Tab to add additional rows.

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 of Clinical Teaching / List Certifications
KEY:
A = APTA credentialed. CI
B = Other CI credentialing
C = Cert. clinical specialist
List others / APTA Member
Yes/No / L= Licensed, Number
E= Eligible
T= Temporary
L/E/T
Number / State of
Licensure
Marty Ebert, PT / University of Wisconsin / 1969 / BS / 40 / 40 / A, Manual therapy
Aquatics / No / L/0828 / WA/WI
Margaret Imrie, PT / University of Washington / 1981 / BS / 28 / 23 / Rehab / No / L / WA
Brenda Yost, PT / College of St. Scholastica / 1985 / BS / 22 / 19 / Business health
Manual therapy / No / L / WA
Karen Rice, PT / Eastern Wash University / 1992 / BS / 16 / 2 / Administration / Yes / L / WA
Angie Meloy, PT / Eastern Wash
University / 1995 / BS / 13 / 1 / Administration
Lymphedema / Yes / L / WA
Angela Arkills, PT / Western Univ of
Health Sciences / 2000 / MPT / 8 / 7 / Lymphedema / No / L / WA
Tom Longbottom / Texas Womens University / 1992 / L / WA
Joy Underwood, PTA / Green River Community College / 1983 / AA / 23 / 2 / No / L / OR/WA
Nancy Rush, PTA / Broward Community College / 1986 / AA / 20 / 2 / Licensed MassageTherapist / Yes / L / FL/WA
Jill Sauve, PTA / Green River Community College / 1991 / AA / 15 / 0 / Aquatics / No / L / OR/WA
Sheila Wauzynski, PTA / Illinois Central College / 1986 / AA / 20 / 0 / Lymphedema / No / L / IA/WA
Teresa Maison, PTA / Green River Community College / L / WA
Rita Davis, PT / Eastern Wash
University / 2000 / MPT / 7 / 0 / No / L / OR/WA
Steve Davis, PT / Eastern Wash
University / 1998 / MPT / 10 / 2 / Yes / L / OR/WA
Kevin Cox, PT / Finch University of Health Sciences
Chicago Med. Sch. / 1998 / BS / 10 / 0 / CSCS / Yes / L / WA
Ken McConnehey, PT / University of Utah / 2006 / DPT / 2 / 0 / Yes / L / WA/UT
Ron Walser / University of New Hampshire / 2009 / DPT / I / WA

1

Clinical Instructors

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

APTA Clinical Instructor Credentialing / No criteria
Career ladder opportunity / Other (not APTA) clinical instructor credentialing
Certification/training course / Therapist initiative/volunteer
Clinical competence / Years of experience: Number: 2
Delegated in job description / Other (please specify): Area of clinic they are working in at the time a student is present.
Demonstrated strength in clinical teaching

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

1:1 individual training (CCCE:CI) / Continuing education by consortia
Academic for-credit coursework / No training
APTA Clinical Instructor Education and Credentialing Program / Other (not APTA) clinical instructor credentialing program
Clinical center inservices / Professional continuing education (eg, chapter, CEU course)
Continuing education by academic program / Other (please specify):

Information About the Physical Therapy Service

Number of Inpatient Beds

For clinical sites with inpatient care, please provide the number of beds available in each of the subcategories listed below: (If this does not apply to your facility, please skip and move to the next table.)

Acute care / 140 / Psychiatric center
Intensive care / 13 / Rehabilitation center / 17
Step down / 10 / Other specialty centers: Specify
Subacute/transitional care unit
Extended care / Total Number of Beds / 170

Number of Patients/Clients

Estimate the average number of patient/clientvisits per day:

INPATIENT / OUTPATIENT
12-20 / Individual PT / 10 / Individual PT
6-8 / Student PT / 6-8 / Student PT
12-20 / Individual PTA / 10 / Individual PTA
6-8 / Student PTA / 6-8 / Student PTA
PT/PTA Team / PT/PTA Team
30-40 / Total patient/client visits per day / 50-60 / 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%)

Click on the gray bar under rating to select from the drop down box.

Rating / Patient Lifespan / Rating / Continuum of Care
12345 / 0-12 years / 12345 / Critical care, ICU, acute
12345 / 13-21 years / 12345 / SNF/ECF/sub-acute
12345 / 22-65 years / 12345 / Rehabilitation
12345 / Over 65 years / 12345 / Ambulatory/outpatient
12345 / Home health/hospice
12345 / 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%)

2.Check (√) those patient/client diagnostic sub-categories available to the student.

Click on the gray bar under rating to select from the drop down box.

(1-5) / Musculoskeletal
12345 / Acute injury / 12345 / Muscle disease/dysfunction
12345 / Amputation / 12345 / Musculoskeletal degenerative disease
12345 / Arthritis / 12345 / Orthopedic surgery
12345 / Bone disease/dysfunction / 12345 / Other: (Specify)
12345 / Connective tissue disease/dysfunction
(1-5) / Neuro-muscular
12345 / Brain injury / 12345 / Peripheral nerve injury
12345 / Cerebral vascular accident / 12345 / Spinal cord injury
12345 / Chronic pain / 12345 / Vestibular disorder
12345 / Congenital/developmental / 12345 / Other: (Specify)
12345 / Neuromuscular degenerative disease
(1-5) / Cardiovascular-pulmonary
12345 / Cardiac dysfunction/disease / 12345 / Peripheral vascular dysfunction/disease
12345 / Fitness / 12345 / Other: (Specify) Cardiac surgery
12345 / Lymphedema
12345 / Pulmonary dysfunction/disease
(1-5) / Integumentary
12345 / Burns / 12345 / Other: (Specify)
12345 / Open wounds
12345 / Scar formation
(1-5) / Other (May cross a number of diagnostic groups)
12345 / Cognitive impairment / 12345 / Organ transplant
12345 / General medical conditions / 12345 / Wellness/Prevention
12345 / General surgery / 12345 / Other: (Specify)
12345 / Oncologic conditions

Hours of Operation

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

Days of the Week / From: (a.m.) / To: (p.m.) / Comments
Monday / 7:30 / 6:00 / Hours vary depending on the area assigned.
Tuesday / " / " / Rehab unit - 8:00 to 4:30
Wednesday / " / " / Acute hosp - 4 10's 7:30 to 6:00
Thursday / " / " / Outpatient - 4 10's 7:30 to 6:00
Friday / " / "
Saturday / Therpist's normal schedule / 1 Therapist and 1 PT/ PTA in the hospital
Sunday / " / As above

Student Schedule

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

Standard 8 hour day

Varied schedules

Describe the schedule(s) the student is expected to follow during the clinical experience:
Students will follow the same schedule as the CI unless scheduled vacation days occur then the student will have a different therapist assigned to supervise their activities. Most of our therapists do work part-time so the students will be exposed to more than one persons techniques.

Staffing

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

Full-time budgeted / Part-time budgeted / Current Staffing
PTs / 12 / 3 / 9 full and 4 part time
PTAs / 2 / 3 / 2 full and 3 part time
Aides/Techs / 2 / 1 PERDIEM / 3
Others: Specify

Information About the Clinical Education Experience

Special Programs/Activities/Learning Opportunities

Please mark (X) all special programs/activities/learning opportunities available to students.

Administration / Industrial/ergonomic PT / Quality Assurance/CQI/TQM
Aquatic therapy / Inservice training/lectures / Radiology
Athletic venue coverage / Neonatal care / Research experience
Back school / Nursing home/ECF/SNF / Screening/prevention
Biomechanics lab / Orthotic/Prosthetic fabrication / Sports physical therapy
Cardiac rehabilitation / Pain management program / Surgery (observation)
Community/re-entry activities / Pediatric-general (emphasis on): / Team meetings/rounds
Critical care/intensive care / Classroom consultation / Vestibular rehab
Departmental administration / Developmental program / Women’s Health/OB-GYN
Early intervention / Cognitive impairment / Work Hardening/conditioning
Employee intervention / Musculoskeletal / Wound care
Employee wellness program / Neurological / Other (specify below)
Group programs/classes / Prevention/wellness
Home health program / Pulmonary rehabilitation

Specialty Clinics