This survey should be completed by the clinical instructor who directly supervised the student.

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* 1. Clinical Instructor Name:

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* 2. Name of Clinical Facility:

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* 3. Number of years as a CI:

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* 4. Number of PT and PTA students supervised within the last 12 months:

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* 5. Are you an APTA Credentialed Clinical Instructor?

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* 6. List your main strengths as a CI:

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* 7. List your main development needs as a CI:

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* 8. Name a least one way New River Community and Technical College PTA program can assist your development as a CI:

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