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.
