EASTERN FLORIDA STATE COLLEGE
PHYSICAL THERAPIST ASSISTANT PROGRAM
CLINICAL SITE FORM
Name of Facility: Date:
Clinical Coordinator Clinical Education (CCCE) is the person at the facility who will be responsible for the
clinical education process of the student. Please write name and credentials.
Facility Address: (include city, state, and zip code)
Phone Number: Extension: Fax Number:
E-mail Address: Website:
All EFSC PTA students will have the following criteria completed prior to their clinical practicum:
- Proof of health clearance and required vaccinations (TDP, MMR, Hepatitis B, Varicella, Influenza, TB)
- Drug screen and background check
- First aid and CPR certified
- HIPAA and OSHA educated
- Personal health insurance
- Professional liability insurance
If your clinical facility has other specific requirements than those listed above, please specify below:
Which of the following best describes the ownership category for your clinical site?
Corporate/privately owned Government Agency Hospital
Physician owned PT/PTA owner Other
Which of the following best describes the type of facility you are:
Acute care/Inpatient Industrial/Occupational Health
School/Pre-School Program Ambulatory Care/Outpatient
Multiple-level Medical Center Wellness/Prevention Program
Nursing Home/SNF Private Practice
Home Health Care Federal/State/County Health
Sub-acute Rehabilitation
Which best describes your location site?
Rural Suburban Urban
Please select which days your clinical facility is seeing physical therapy patients.
Monday Tuesday Wednesday Thursday Friday
Saturday Sunday
What are your hours of operation? (Please specify if variation between days of the week.)
Please indicate the number of Physical Therapy Department Staff at your clinical facility:
Full-time PT Full-time PTA Full-time Aide/Tech
Part-time PT Part-time
PTA
Part-time Aide/Tech
PRN PT PRN PTA PRN Aide/Tech
Please select all special programs/activities/learning opportunities available to students.
Administration Industrial/ergonomic PT Quality Assurance/CQI/TQM
Aquatic Therapy Inservice Training/Lectures Radiology
Athletic venue coverage Neonatal care Research experience
Back school Nursing Home/ECF/SNF Screening/prevention
Biomechanics Lab Orthotic/Prosthetic Sports PT
Cardiac Pain Management Surgery (observation)
Community/Re-entry Pediatric Team meetings/rounds
Critical Care/ICU Classroom consultation Vestibular Rehab
Departmental Administration Developmental Program Women's Health/OBGYN
Early Intervention Cognitive Impairment Work Hardening
Employee Intervention Musculoskeletal Wound Care
Employee Wellness Neurological Group Programs/Classes
Prevention/Wellness Home Health Pulmonary Rehab
Other (please specify)
Please select all specialty clinics available as student learning experiences.
Arthritis Balance Pain Clinic
Developmental Feeding Clinic Prosthetic/Orthotic
Scoliosis Hand Clinic Seating/Mobility
Pre-participation Sports Hemophilia Clinic Sports Medicine Clinic
Wellness Industry Women's Health
Other
Please select all health care and educational providers at your clinical facility students typically observe
and/or with whom they interact.
Administrators Massage Therapist SLP
Nurses Social Workers Athletic Trainers
OT Special Education Audiologists
Physicians/PAs Wound Specialist Podiatrists
Exercise Physiologists Prosthetists/Orthotists Vocational Rehab
Fitness Professionals Psychologists Health Information Tech
Respiratory Therapists Other
OPTIONAL: Please feel free to use the space provided below to share additional information about your
clinical site. For example, strengths, special learning opportunities, clinical supervision, organizational
structure, clinical philosophies of treatment, pacing expectations of students, etc.
Please provide the following information on all PTs and PTAs employed at your clinical site who are
classified as Clinical Instructors.
Name followed by credentials
PT/PTA Program in which CI
graduated
Year of Graduation License #
Highest earned physical
therapy degree
# of years of Clinical Practice # of years of Clinical Teaching
CI Certifications (if any)
Name followed by credentials
PT/PTA Program in which CI
graduated
Year of Graduation License #
Highest earned physical
therapy degree
# of years of Clinical Practice # of years of Clinical Teaching
CI Certifications (if any)
License #
# of years of Clinical Teaching
Name followed by credentials
PT/PTA Program in which CI
graduated
Year of Graduation
Highest earned physical
therapy degree
# of years of Clinical Practice
CI Certifications (if any)
License #
# of years of Clinical Teaching
Name followed by credentials
PT/PTA Program in which CI
graduated
Year of Graduation
Highest earned physical
therapy degree
# of years of Clinical Practice
CI Certifications (if any)