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CLINICAL SITE/CENTER INFORMATION FORM

1.Date of form completion
Date / Time
2.Name of Clinical Site/Facility 
3.Name of the Site/Center Coordinator of Clinical Education (SCCE/CCCE)
4.Contact information for SCCE/CCCE
5.Facility Address (Primary Location)
If you have multiple clinic locations please complete the following questions about those sites.  Where information is the same as the primary clinical site, indicate SAME.  
6.Facility Address (Secondary Location if applicable)
7.Facility Address (Secondary Location if applicable)
8.Which of the following best describes the ownership category for your clinical site? (check all that apply)

 
9.Indicate the categories that best describes how your facility functions (select all that are applicable)
Complete the information below related to EACH of the licensed PTs/PTAs in your facility who will be serving as Clinical Instructors.  If more than 5 facility clinicians would be serving as clinical instructors please email kcox@bpcc.edu to provide their information. 
10.Clinical Instructor #1 - NAME
11.For Clinical Instructor #1 - Check all that apply
12.Clinical Instructor #2 - NAME
13.For Clinical Instructor #2 - Check all that apply
14.Clinical Instructor #3 - NAME
15.For Clinical Instructor #3 - Check all that apply
16.Clinical Instructor #4 - NAME
17.For Clinical Instructor #4 - Check all that apply
18.Clinical Instructor #5 - NAME
19.For Clinical Instructor #5 - Check all that apply
20.What criteria do you use to select clinical instructors (select all that apply)
21.How are clinical instructors in your facility trained? (select all that apply)
22.Describe the typical caseload (patient visits per day) for a clinical instructor in your facility.
23.Indicate (estimate) the frequency with which these categories of patient experiences are seen/available in your facility(ies):
Frequency
Working with patients 0-12 years of age
Working with patients 13-21 years of age
Working with patients 22-65 years of age
Working with patients over 65 years of age
Practicing in a critical care/ICU, acute setting
Practicing in an SNF/ECF/subacute setting
Practicing in an Inpatient Rehabilitation setting
Practicing in an Outpatient setting
Practicing in a Home Health setting
Practicing in a Wellness/Fitness/Industry setting
Treating patients with a Musculoskeletal System Diagnosis (primary or underlying) such as orthopedic injury/surgery, amputation, arthritis, bone disease/dysfunction, connective tissue disease/dysfunction, muscle disease/dysfunction, musculoskeletal degenerative diseases, or other disorders of this system.
Treating patients with a Neuromuscular System Diagnosis (primary or underlying) such as brain injury, CVA, chronic pain, congenital/developmental, neuromuscular degenerative disorder, peripheral nerve injury, spinal cord injury, vestibular disorder, or other disorders of this system
Treating patients with a Cardiovascular or Pulmonary Diagnosis (primary or underlying) such as cardiac disease, peripheral vascular disease, pulmonary dysfunction/disease, lymphedema, or other disorders of these systems
Treating patients with an Integumentary System Diagnosis (primary or underlying) such as burns, wounds, scars, or other disorders of this system
Treating patients with a diagnosis (disorder/disease, surgery) affecting "other" systems of the body (primary or underlying) such as gastrointestinal, genitourinary, reproductive, renal, endocrine, immune/autoimmune, cognitive, oncologic, hematologic, etc.
24.Describe the hours of operation for your facility and the typical schedule a student would be expected to follow during the clinical experience. 
25.Indicate if any of these special learning opportunities are available to students in your facility (check all that apply). 
26.Indicate which of these other individuals and healthcare professions/providers at your facility a student would typically have the opportunity to work with/interact with (select all that apply). 
27.Which of these methods are used by the SCCE/CCCE and/or clinical instructors to orient students to the facility/expectations of the site and provide ongoing feedback to students related to their performance?  (select all that apply)
28.If your facility provides housing, meals, stipend or other services/benefits to students during a clinical rotation please describe:
29.BPCC PTA students are required to complete/submit the following immunizations/certifications/etc:  TB test, Hep B titer, MMR (vaccine record/titer), Varicella titer, Rubella/Rubeola titer, Influenza vaccine, Covid 19 (vaccine or exemption), AHA BLS certification, HIPAA/OSHA training certification, physician signed physical exam/health status statement, background check, drug screen, and student signed confidentiality (HIPAA) statement.  Additionally students are provided with liability insurance coverage.  If your facility has additional requirements please comment on those below.
30.Please feel free to provide any additional information regarding your facility's clinical education program, expectation for student preparation/performance, unique opportunities, or specific needs.
THANK YOU for completing this form!!  We look forward to working with you to provide BPCC PTA students with an excellent clinical education experience!!  Please feel free to contact me at any time with questions or concerns!!  

Kim Cox, PT, MEd
BPCC PTA Program ACCE
office:  (318) 678-6107
email:  kcox@bpcc.edu
cell:  (318) 464-1928