Clinical Educator Demographic Data Sheet
To be completed by the clinical educator
1. Name (4 letters): (please use initial of first name and first 3 letters of last name) e.g.
Kelly Stanley is ksta ___________
2. Facility Name: ________________________
3. Type of facility (please check all relevant boxes)
Hospital (public)
Hospital (private)
Community based service
Private practice
Non government organisation
Other: ______________________
4. Gender: Female Male
5. Age last birthday ________ (years)
6. Number of years in Clinical Practice ________ years
7. How long have you been involved in the clinical education of physiotherapy students?
_____________years
8. How would you rate your level of experience as a clinical educator? Please circle
No previous experience Very experienced
2 5 1 4 3
9. Have you participated in a clinical educator’s workshop of other training on
assessment?
Yes No
If Yes, please advise year: _________
Please note that the data collected is for University purposes only to support ongoing accreditation
and quality assurance and personal information will not be released to any outside party.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome