UCSF/SFSU GRADUATE PROGRAM IN PHYSICAL THERAPY

FULL-TIME EXPERIENCE MIDTERM CHECK IN

Student: / Facility:
Course: / PT 801 / PT 802 / PT 418 / Date:
Clinical Instructor: / Years as PT: / Years as CI:
APTA Certified CI? / Yes / No / APTA Certified Advanced CI? / Yes / No
Specialty Certification(s):

Student Check In

Supervision

1. Availability & Amount: / Good / Needs Improvement
Comments

Communication – select all that apply

2. Feedback is: / Timely / Constructive / Clear and Concise
Comments
3. Feedback is: / Sufficient / Insufficient – need more feedback
Comments
4. Inservice Topic: / Date:

5. Are there any extra learning experiences planned for your time here? (observations, surgeries, marketing, groups)

6. What are the key strengths and/or areas of improvement for the program?

7. Do you have any suggestions to improve communication from the ACCE?

Signature

I have completed this midterm check in to the best of my ability and agree to report any problems to the DCE as soon as possible: Theresa Jaramillo, 415.514.6773, .

Signature / Date

Clinical Instructor Check In

1. Did you receive information from the school about objectives and grading policies? / Yes / No
2. Does the clinic have overall objectives for the student? / Yes / No
3. Is the student meeting your expectations at this point? / Yes / No

Comments:

4. Do you have any significant concerns regarding the student? / Yes / No

Describe:

5. Any critical incidents? / Yes / No / (If yes, please describe below.)

Comments:

6. Even though a midterm visit/phone call has not been scheduled,

would you like to be contacted by a core faculty member? / Yes / No
Initial here

If yes, provide your contact information:

Phone:

Email:

7. What are the key strengths and/or areas of improvement for the program?

8. Do you have any suggestions to improve communication from the ACCE?

Signature

I have completed this midterm check in to the best of my ability and agree to follow my responsibilities as outlined in the information provided in the student package.

Signature / Date

After completing this form during your midterm review, please send a copy of the signed form to
Theresa Jaramillo by email () or fax (415.514.6778).