Clinical Instructor Evaluation of Clinical Education Program

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* 1. Please provide feedback about the ACCE with regard to the affiliation listed below.

Date:

Name (Optional):

Question Title

* 2. Please rate the preparation of the student in the following areas:

	Excellent	Good	Average	Fair	Poor	N/A
Providing patient care and safety	Providing patient care and safety Excellent	Providing patient care and safety Good	Providing patient care and safety Average	Providing patient care and safety Fair	Providing patient care and safety Poor	Providing patient care and safety N/A
Performance of assessment skills within the scope of practice	Performance of assessment skills within the scope of practice Excellent	Performance of assessment skills within the scope of practice Good	Performance of assessment skills within the scope of practice Average	Performance of assessment skills within the scope of practice Fair	Performance of assessment skills within the scope of practice Poor	Performance of assessment skills within the scope of practice N/A
Use of physical agents for patient care	Use of physical agents for patient care Excellent	Use of physical agents for patient care Good	Use of physical agents for patient care Average	Use of physical agents for patient care Fair	Use of physical agents for patient care Poor	Use of physical agents for patient care N/A
Use of basic therapeutic exercises	Use of basic therapeutic exercises Excellent	Use of basic therapeutic exercises Good	Use of basic therapeutic exercises Average	Use of basic therapeutic exercises Fair	Use of basic therapeutic exercises Poor	Use of basic therapeutic exercises N/A
Development of rehabilitation program for patients with orthopedic conditions	Development of rehabilitation program for patients with orthopedic conditions Excellent	Development of rehabilitation program for patients with orthopedic conditions Good	Development of rehabilitation program for patients with orthopedic conditions Average	Development of rehabilitation program for patients with orthopedic conditions Fair	Development of rehabilitation program for patients with orthopedic conditions Poor	Development of rehabilitation program for patients with orthopedic conditions N/A
Development of rehabilitation program for patients with amputations	Development of rehabilitation program for patients with amputations Excellent	Development of rehabilitation program for patients with amputations Good	Development of rehabilitation program for patients with amputations Average	Development of rehabilitation program for patients with amputations Fair	Development of rehabilitation program for patients with amputations Poor	Development of rehabilitation program for patients with amputations N/A
Development of rehabilitation program for patients with cardiac conditions	Development of rehabilitation program for patients with cardiac conditions Excellent	Development of rehabilitation program for patients with cardiac conditions Good	Development of rehabilitation program for patients with cardiac conditions Average	Development of rehabilitation program for patients with cardiac conditions Fair	Development of rehabilitation program for patients with cardiac conditions Poor	Development of rehabilitation program for patients with cardiac conditions N/A
Development of rehabilitation program for patients with pulmonary conditions	Development of rehabilitation program for patients with pulmonary conditions Excellent	Development of rehabilitation program for patients with pulmonary conditions Good	Development of rehabilitation program for patients with pulmonary conditions Average	Development of rehabilitation program for patients with pulmonary conditions Fair	Development of rehabilitation program for patients with pulmonary conditions Poor	Development of rehabilitation program for patients with pulmonary conditions N/A
Development of rehabilitation program for patients with neurological conditions	Development of rehabilitation program for patients with neurological conditions Excellent	Development of rehabilitation program for patients with neurological conditions Good	Development of rehabilitation program for patients with neurological conditions Average	Development of rehabilitation program for patients with neurological conditions Fair	Development of rehabilitation program for patients with neurological conditions Poor	Development of rehabilitation program for patients with neurological conditions N/A
Development of rehabilitation program for patients with burns	Development of rehabilitation program for patients with burns Excellent	Development of rehabilitation program for patients with burns Good	Development of rehabilitation program for patients with burns Average	Development of rehabilitation program for patients with burns Fair	Development of rehabilitation program for patients with burns Poor	Development of rehabilitation program for patients with burns N/A
Assist with program planning and implementation	Assist with program planning and implementation Excellent	Assist with program planning and implementation Good	Assist with program planning and implementation Average	Assist with program planning and implementation Fair	Assist with program planning and implementation Poor	Assist with program planning and implementation N/A
Practicing under the supervision of a physical therapist in an ethical, legal, safe and effective manner	Practicing under the supervision of a physical therapist in an ethical, legal, safe and effective manner Excellent	Practicing under the supervision of a physical therapist in an ethical, legal, safe and effective manner Good	Practicing under the supervision of a physical therapist in an ethical, legal, safe and effective manner Average	Practicing under the supervision of a physical therapist in an ethical, legal, safe and effective manner Fair	Practicing under the supervision of a physical therapist in an ethical, legal, safe and effective manner Poor	Practicing under the supervision of a physical therapist in an ethical, legal, safe and effective manner N/A
Implement a comprehensive treatment plan as developed by a physical therapist	Implement a comprehensive treatment plan as developed by a physical therapist Excellent	Implement a comprehensive treatment plan as developed by a physical therapist Good	Implement a comprehensive treatment plan as developed by a physical therapist Average	Implement a comprehensive treatment plan as developed by a physical therapist Fair	Implement a comprehensive treatment plan as developed by a physical therapist Poor	Implement a comprehensive treatment plan as developed by a physical therapist N/A
Effective communication with the supervising physical therapist about patient treatment	Effective communication with the supervising physical therapist about patient treatment Excellent	Effective communication with the supervising physical therapist about patient treatment Good	Effective communication with the supervising physical therapist about patient treatment Average	Effective communication with the supervising physical therapist about patient treatment Fair	Effective communication with the supervising physical therapist about patient treatment Poor	Effective communication with the supervising physical therapist about patient treatment N/A
Appropriate measurement techniques within limits of practice	Appropriate measurement techniques within limits of practice Excellent	Appropriate measurement techniques within limits of practice Good	Appropriate measurement techniques within limits of practice Average	Appropriate measurement techniques within limits of practice Fair	Appropriate measurement techniques within limits of practice Poor	Appropriate measurement techniques within limits of practice N/A
Interaction with patients and families in an effective manner	Interaction with patients and families in an effective manner Excellent	Interaction with patients and families in an effective manner Good	Interaction with patients and families in an effective manner Average	Interaction with patients and families in an effective manner Fair	Interaction with patients and families in an effective manner Poor	Interaction with patients and families in an effective manner N/A
Appropriate documentation	Appropriate documentation Excellent	Appropriate documentation Good	Appropriate documentation Average	Appropriate documentation Fair	Appropriate documentation Poor	Appropriate documentation N/A
Independent thinking skills	Independent thinking skills Excellent	Independent thinking skills Good	Independent thinking skills Average	Independent thinking skills Fair	Independent thinking skills Poor	Independent thinking skills N/A
Critical thinking skills	Critical thinking skills Excellent	Critical thinking skills Good	Critical thinking skills Average	Critical thinking skills Fair	Critical thinking skills Poor	Critical thinking skills N/A
Communication skills	Communication skills Excellent	Communication skills Good	Communication skills Average	Communication skills Fair	Communication skills Poor	Communication skills N/A
Commitment to continuing personal and professional growth	Commitment to continuing personal and professional growth Excellent	Commitment to continuing personal and professional growth Good	Commitment to continuing personal and professional growth Average	Commitment to continuing personal and professional growth Fair	Commitment to continuing personal and professional growth Poor	Commitment to continuing personal and professional growth N/A
Exemplifies the Standards of Practice for Physical Therapy, the Standards of Conduct for Physical Therapist Assistant, and the Guide for Conduct of the Affiliate Manner	Exemplifies the Standards of Practice for Physical Therapy, the Standards of Conduct for Physical Therapist Assistant, and the Guide for Conduct of the Affiliate Manner Excellent	Exemplifies the Standards of Practice for Physical Therapy, the Standards of Conduct for Physical Therapist Assistant, and the Guide for Conduct of the Affiliate Manner Good	Exemplifies the Standards of Practice for Physical Therapy, the Standards of Conduct for Physical Therapist Assistant, and the Guide for Conduct of the Affiliate Manner Average	Exemplifies the Standards of Practice for Physical Therapy, the Standards of Conduct for Physical Therapist Assistant, and the Guide for Conduct of the Affiliate Manner Fair	Exemplifies the Standards of Practice for Physical Therapy, the Standards of Conduct for Physical Therapist Assistant, and the Guide for Conduct of the Affiliate Manner Poor	Exemplifies the Standards of Practice for Physical Therapy, the Standards of Conduct for Physical Therapist Assistant, and the Guide for Conduct of the Affiliate Manner N/A
Practices within the scope of the PTA's ability in the delivery of care	Practices within the scope of the PTA's ability in the delivery of care Excellent	Practices within the scope of the PTA's ability in the delivery of care Good	Practices within the scope of the PTA's ability in the delivery of care Average	Practices within the scope of the PTA's ability in the delivery of care Fair	Practices within the scope of the PTA's ability in the delivery of care Poor	Practices within the scope of the PTA's ability in the delivery of care N/A
Appropriate discharge criteria and procedures and follow up care	Appropriate discharge criteria and procedures and follow up care Excellent	Appropriate discharge criteria and procedures and follow up care Good	Appropriate discharge criteria and procedures and follow up care Average	Appropriate discharge criteria and procedures and follow up care Fair	Appropriate discharge criteria and procedures and follow up care Poor	Appropriate discharge criteria and procedures and follow up care N/A
Activities of daily living	Activities of daily living Excellent	Activities of daily living Good	Activities of daily living Average	Activities of daily living Fair	Activities of daily living Poor	Activities of daily living N/A
Assistive devices	Assistive devices Excellent	Assistive devices Good	Assistive devices Average	Assistive devices Fair	Assistive devices Poor	Assistive devices N/A
Gait training	Gait training Excellent	Gait training Good	Gait training Average	Gait training Fair	Gait training Poor	Gait training N/A
Balance training	Balance training Excellent	Balance training Good	Balance training Average	Balance training Fair	Balance training Poor	Balance training N/A
Developmental activities	Developmental activities Excellent	Developmental activities Good	Developmental activities Average	Developmental activities Fair	Developmental activities Poor	Developmental activities N/A
Electric current	Electric current Excellent	Electric current Good	Electric current Average	Electric current Fair	Electric current Poor	Electric current N/A
Electromagnetic radiation	Electromagnetic radiation Excellent	Electromagnetic radiation Good	Electromagnetic radiation Average	Electromagnetic radiation Fair	Electromagnetic radiation Poor	Electromagnetic radiation N/A
External compression	External compression Excellent	External compression Good	External compression Average	External compression Fair	External compression Poor	External compression N/A
Hydrotherapy	Hydrotherapy Excellent	Hydrotherapy Good	Hydrotherapy Average	Hydrotherapy Fair	Hydrotherapy Poor	Hydrotherapy N/A
Orthotics	Orthotics Excellent	Orthotics Good	Orthotics Average	Orthotics Fair	Orthotics Poor	Orthotics N/A
Prosthetics	Prosthetics Excellent	Prosthetics Good	Prosthetics Average	Prosthetics Fair	Prosthetics Poor	Prosthetics N/A
Patient/Family education	Patient/Family education Excellent	Patient/Family education Good	Patient/Family education Average	Patient/Family education Fair	Patient/Family education Poor	Patient/Family education N/A
Postural training	Postural training Excellent	Postural training Good	Postural training Average	Postural training Fair	Postural training Poor	Postural training N/A
Body mechanics	Body mechanics Excellent	Body mechanics Good	Body mechanics Average	Body mechanics Fair	Body mechanics Poor	Body mechanics N/A
Pulmonary hygiene techniques	Pulmonary hygiene techniques Excellent	Pulmonary hygiene techniques Good	Pulmonary hygiene techniques Average	Pulmonary hygiene techniques Fair	Pulmonary hygiene techniques Poor	Pulmonary hygiene techniques N/A
Therapeutic exercise	Therapeutic exercise Excellent	Therapeutic exercise Good	Therapeutic exercise Average	Therapeutic exercise Fair	Therapeutic exercise Poor	Therapeutic exercise N/A
Therapeutic massage	Therapeutic massage Excellent	Therapeutic massage Good	Therapeutic massage Average	Therapeutic massage Fair	Therapeutic massage Poor	Therapeutic massage N/A
Thermal agents	Thermal agents Excellent	Thermal agents Good	Thermal agents Average	Thermal agents Fair	Thermal agents Poor	Thermal agents N/A
Iontophoresis	Iontophoresis Excellent	Iontophoresis Good	Iontophoresis Average	Iontophoresis Fair	Iontophoresis Poor	Iontophoresis N/A
Traction	Traction Excellent	Traction Good	Traction Average	Traction Fair	Traction Poor	Traction N/A
Ultrasound	Ultrasound Excellent	Ultrasound Good	Ultrasound Average	Ultrasound Fair	Ultrasound Poor	Ultrasound N/A
Universal precautions/infection control	Universal precautions/infection control Excellent	Universal precautions/infection control Good	Universal precautions/infection control Average	Universal precautions/infection control Fair	Universal precautions/infection control Poor	Universal precautions/infection control N/A
Wound care	Wound care Excellent	Wound care Good	Wound care Average	Wound care Fair	Wound care Poor	Wound care N/A
Architectural barriers and environmental modifications	Architectural barriers and environmental modifications Excellent	Architectural barriers and environmental modifications Good	Architectural barriers and environmental modifications Average	Architectural barriers and environmental modifications Fair	Architectural barriers and environmental modifications Poor	Architectural barriers and environmental modifications N/A
Joint range of motion	Joint range of motion Excellent	Joint range of motion Good	Joint range of motion Average	Joint range of motion Fair	Joint range of motion Poor	Joint range of motion N/A
Functional activities	Functional activities Excellent	Functional activities Good	Functional activities Average	Functional activities Fair	Functional activities Poor	Functional activities N/A
Pain	Pain Excellent	Pain Good	Pain Average	Pain Fair	Pain Poor	Pain N/A
Righting and equilibrium reactions	Righting and equilibrium reactions Excellent	Righting and equilibrium reactions Good	Righting and equilibrium reactions Average	Righting and equilibrium reactions Fair	Righting and equilibrium reactions Poor	Righting and equilibrium reactions N/A
Girth and volume measurements	Girth and volume measurements Excellent	Girth and volume measurements Good	Girth and volume measurements Average	Girth and volume measurements Fair	Girth and volume measurements Poor	Girth and volume measurements N/A
Sensation	Sensation Excellent	Sensation Good	Sensation Average	Sensation Fair	Sensation Poor	Sensation N/A
Strength	Strength Excellent	Strength Good	Strength Average	Strength Fair	Strength Poor	Strength N/A
Vital signs	Vital signs Excellent	Vital signs Good	Vital signs Average	Vital signs Fair	Vital signs Poor	Vital signs N/A

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* 3. In which areas do you feel the student was best prepared for the clinical?

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* 4. In which areas do you feel additional preparation is needed?

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* 5. Additional input you would like to provide.

Thanks for your time. Your feedback is essential to the continued success of the program.