New Clinical Site Questionnaire

Site Name * Required
Site Mailing Address
Coordinator For Clin.Ed. (SCCE) Name and Credentials * Required
Coordinator For Clin.Ed. E-Mail * Required
Coordinator For Clin.Ed. Phone Number * Required
Site Fax Number
Site Website
Director of Rehab or Owner Name, Email and Phone Number
Contact Person for Clinical Education Contracts (if Different from SCCE Above)
Please Provide Name, Email, Phone Number
Contracting Entity (Legal Name) of Facility
Facility Ownership
Site Description
Describe the facility and patients served
Does the Clinic Accept Insurance or are Services Cash-Based Only?
Number Of PTs On Staff
Number Of PTAs, Aids and Other Staff
Special Certifications Of PTs On Staff
Number Of APTA Credentialed CIs
Approximate % of Staff
Number Of APTA Members
Approximate % of Staff
Special Certifications Of PTs
Do You Offer Any Special Benefits to Students?
Housing, Stipend, Etc.
Are Patients Seen At More Than One Location?
- Yes
- No
If Multiple Locations, Please List Additional Locations
What is Your Philosophy of Care or Approach to Patients?
What Makes Your Site A Meaningful Learning Environment For PT Students?
What, if Anything, Do You Need from the School to Help You Provide Clinical Education to Students?
Anything Else You'd Like to Share