Student Evaluation of the Clinical Experience

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* 1. Please complete this evaluation after each clinical affiliation. Once completed, return this form to your ACCE as required.

Student Name:

CI Name:

Facility Name:

Affiliation Dates:

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* 2. Did you select this facility for an affiliation?

Yes

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* 3. To gain knowledge about selecting this clinical affiliation, what sources did you use?

	No	Yes
Letter about the Program	Letter about the Program No	Letter about the Program Yes
Pamphlets, notebooks, etc.	Pamphlets, notebooks, etc. No	Pamphlets, notebooks, etc. Yes
Audiovisual slides tapes, etc.	Audiovisual slides tapes, etc. No	Audiovisual slides tapes, etc. Yes
Visit to or by facility	Visit to or by facility No	Visit to or by facility Yes
Information from faculty (including ACCE)	Information from faculty (including ACCE) No	Information from faculty (including ACCE) Yes
Information from students	Information from students No	Information from students Yes
After your orientation to this facility, did you know what would be expected of you?	After your orientation to this facility, did you know what would be expected of you? No	After your orientation to this facility, did you know what would be expected of you? Yes

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* 4. During your affiliation at this site were the students who were affiliating:

	No	Yes
From other Physical Therapist Assistant Programs?	From other Physical Therapist Assistant Programs? No	From other Physical Therapist Assistant Programs? Yes
With other disciplines or service departments?	With other disciplines or service departments? No	With other disciplines or service departments? Yes
Were you required to present an in-service program?	Were you required to present an in-service program? No	Were you required to present an in-service program? Yes

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* 5. What special learning experiences were available to you during this affiliation?

	No	Yes
Clinics (amputee, hand, etc.)	Clinics (amputee, hand, etc.) No	Clinics (amputee, hand, etc.) Yes
Famliy conferences	Famliy conferences No	Famliy conferences Yes
Home visits	Home visits No	Home visits Yes
Patient conferences	Patient conferences No	Patient conferences Yes
Surgery observation	Surgery observation No	Surgery observation Yes
X-ray viewing	X-ray viewing No	X-ray viewing Yes
Diagnostic testing	Diagnostic testing No	Diagnostic testing Yes
Specialized classes	Specialized classes No	Specialized classes Yes
Research activities	Research activities No	Research activities Yes
Administrative activities	Administrative activities No	Administrative activities Yes
Other	Other No	Other Yes
Did you participate in selecting your patient load?	Did you participate in selecting your patient load? No	Did you participate in selecting your patient load? Yes
Did you receive feedback about your clinical performance only during the mid-term and final evaluations?	Did you receive feedback about your clinical performance only during the mid-term and final evaluations? No	Did you receive feedback about your clinical performance only during the mid-term and final evaluations? Yes
Were you given the opportunity to discuss your self-evaluation?	Were you given the opportunity to discuss your self-evaluation? No	Were you given the opportunity to discuss your self-evaluation? Yes
Was the supervision provided adequate for your level?	Was the supervision provided adequate for your level? No	Was the supervision provided adequate for your level? Yes

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* 6. How many other students was your clinical instructor directly supervising?

No Students

1 Student

2 Students

3 Students

4 Students

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* 7. How many PT students were affiliating at the facility?

No Students

1 Student

2 Students

3 Students

4 Students

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* 8. How many other PTA students were affiliating at the facility?

No Students

1 Student

2 Students

3 Students

4 Students

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* 9. Describe the following information that was made available to you prior to your clinical education experience:

	Not applicable	Useless	Misleading	Somewhat helpful	Definitely helpful
Support services (room, board, parking)	Support services (room, board, parking) Not applicable	Support services (room, board, parking) Useless	Support services (room, board, parking) Misleading	Support services (room, board, parking) Somewhat helpful	Support services (room, board, parking) Definitely helpful
Cost of support services	Cost of support services Not applicable	Cost of support services Useless	Cost of support services Misleading	Cost of support services Somewhat helpful	Cost of support services Definitely helpful
Travel information	Travel information Not applicable	Travel information Useless	Travel information Misleading	Travel information Somewhat helpful	Travel information Definitely helpful
Schedule of working hours	Schedule of working hours Not applicable	Schedule of working hours Useless	Schedule of working hours Misleading	Schedule of working hours Somewhat helpful	Schedule of working hours Definitely helpful
Uniform requirements	Uniform requirements Not applicable	Uniform requirements Useless	Uniform requirements Misleading	Uniform requirements Somewhat helpful	Uniform requirements Definitely helpful
Location of site	Location of site Not applicable	Location of site Useless	Location of site Misleading	Location of site Somewhat helpful	Location of site Definitely helpful
Types of patients served	Types of patients served Not applicable	Types of patients served Useless	Types of patients served Misleading	Types of patients served Somewhat helpful	Types of patients served Definitely helpful
Specialty programs available	Specialty programs available Not applicable	Specialty programs available Useless	Specialty programs available Misleading	Specialty programs available Somewhat helpful	Specialty programs available Definitely helpful
Learning experiences provided	Learning experiences provided Not applicable	Learning experiences provided Useless	Learning experiences provided Misleading	Learning experiences provided Somewhat helpful	Learning experiences provided Definitely helpful
Library facilities	Library facilities Not applicable	Library facilities Useless	Library facilities Misleading	Library facilities Somewhat helpful	Library facilities Definitely helpful
How did you find the information supplied to you about this clinical education?	How did you find the information supplied to you about this clinical education? Not applicable	How did you find the information supplied to you about this clinical education? Useless	How did you find the information supplied to you about this clinical education? Misleading	How did you find the information supplied to you about this clinical education? Somewhat helpful	How did you find the information supplied to you about this clinical education? Definitely helpful

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* 10. Describe the amount of space that was available to you for:

	N/A	Inadequate	Somewhat lacking	Adequate	Good
Accomodating personal belongings	Accomodating personal belongings N/A	Accomodating personal belongings Inadequate	Accomodating personal belongings Somewhat lacking	Accomodating personal belongings Adequate	Accomodating personal belongings Good
Charting and record keeping	Charting and record keeping N/A	Charting and record keeping Inadequate	Charting and record keeping Somewhat lacking	Charting and record keeping Adequate	Charting and record keeping Good
Studying	Studying N/A	Studying Inadequate	Studying Somewhat lacking	Studying Adequate	Studying Good
Counseling/discussing with clinical instructor	Counseling/discussing with clinical instructor N/A	Counseling/discussing with clinical instructor Inadequate	Counseling/discussing with clinical instructor Somewhat lacking	Counseling/discussing with clinical instructor Adequate	Counseling/discussing with clinical instructor Good
Treating patients	Treating patients N/A	Treating patients Inadequate	Treating patients Somewhat lacking	Treating patients Adequate	Treating patients Good

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* 11. Describe the support services that were provided to you:

	N/A	Inadequate	Somewhat lacking	Adequate	Good
Housing	Housing N/A	Housing Inadequate	Housing Somewhat lacking	Housing Adequate	Housing Good
Meals	Meals N/A	Meals Inadequate	Meals Somewhat lacking	Meals Adequate	Meals Good
Laundry	Laundry N/A	Laundry Inadequate	Laundry Somewhat lacking	Laundry Adequate	Laundry Good
Parking	Parking N/A	Parking Inadequate	Parking Somewhat lacking	Parking Adequate	Parking Good

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* 12. Describe the support services that were not provided for you but available:

	N/A	Inadequate	Somewhat lacking	Adequate	Good
Housing	Housing N/A	Housing Inadequate	Housing Somewhat lacking	Housing Adequate	Housing Good
Meals	Meals N/A	Meals Inadequate	Meals Somewhat lacking	Meals Adequate	Meals Good
Laundry	Laundry N/A	Laundry Inadequate	Laundry Somewhat lacking	Laundry Adequate	Laundry Good
Parking	Parking N/A	Parking Inadequate	Parking Somewhat lacking	Parking Adequate	Parking Good

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* 13. Describe your orientation to this facility in:

	N/A	Inadequate	Somewhat lacking	Adequate	Good
Administrative procedures	Administrative procedures N/A	Administrative procedures Inadequate	Administrative procedures Somewhat lacking	Administrative procedures Adequate	Administrative procedures Good
Departmental organization	Departmental organization N/A	Departmental organization Inadequate	Departmental organization Somewhat lacking	Departmental organization Adequate	Departmental organization Good
Personnel policies	Personnel policies N/A	Personnel policies Inadequate	Personnel policies Somewhat lacking	Personnel policies Adequate	Personnel policies Good
Standards of the department	Standards of the department N/A	Standards of the department Inadequate	Standards of the department Somewhat lacking	Standards of the department Adequate	Standards of the department Good
Scheduled daily/weekly activities	Scheduled daily/weekly activities N/A	Scheduled daily/weekly activities Inadequate	Scheduled daily/weekly activities Somewhat lacking	Scheduled daily/weekly activities Adequate	Scheduled daily/weekly activities Good
Staff personnel introductions	Staff personnel introductions N/A	Staff personnel introductions Inadequate	Staff personnel introductions Somewhat lacking	Staff personnel introductions Adequate	Staff personnel introductions Good
Physical layout	Physical layout N/A	Physical layout Inadequate	Physical layout Somewhat lacking	Physical layout Adequate	Physical layout Good
The orientation you received after arrival at this center was	The orientation you received after arrival at this center was N/A	The orientation you received after arrival at this center was Inadequate	The orientation you received after arrival at this center was Somewhat lacking	The orientation you received after arrival at this center was Adequate	The orientation you received after arrival at this center was Good
The learning experiences provided by this institution were	The learning experiences provided by this institution were N/A	The learning experiences provided by this institution were Inadequate	The learning experiences provided by this institution were Somewhat lacking	The learning experiences provided by this institution were Adequate	The learning experiences provided by this institution were Good
The variety of patients available to you to master the skills you selected was	The variety of patients available to you to master the skills you selected was N/A	The variety of patients available to you to master the skills you selected was Inadequate	The variety of patients available to you to master the skills you selected was Somewhat lacking	The variety of patients available to you to master the skills you selected was Adequate	The variety of patients available to you to master the skills you selected was Good
The amount of time available for communications/discussions with your clinical instructor was	The amount of time available for communications/discussions with your clinical instructor was N/A	The amount of time available for communications/discussions with your clinical instructor was Inadequate	The amount of time available for communications/discussions with your clinical instructor was Somewhat lacking	The amount of time available for communications/discussions with your clinical instructor was Adequate	The amount of time available for communications/discussions with your clinical instructor was Good
The communications/discussions you had with your clinical instructor were	The communications/discussions you had with your clinical instructor were N/A	The communications/discussions you had with your clinical instructor were Inadequate	The communications/discussions you had with your clinical instructor were Somewhat lacking	The communications/discussions you had with your clinical instructor were Adequate	The communications/discussions you had with your clinical instructor were Good
Based on your clinical experience and skill, the degree of supervision you received was	Based on your clinical experience and skill, the degree of supervision you received was N/A	Based on your clinical experience and skill, the degree of supervision you received was Inadequate	Based on your clinical experience and skill, the degree of supervision you received was Somewhat lacking	Based on your clinical experience and skill, the degree of supervision you received was Adequate	Based on your clinical experience and skill, the degree of supervision you received was Good
The feedback you received from your clinical instructor about your clinical performance was	The feedback you received from your clinical instructor about your clinical performance was N/A	The feedback you received from your clinical instructor about your clinical performance was Inadequate	The feedback you received from your clinical instructor about your clinical performance was Somewhat lacking	The feedback you received from your clinical instructor about your clinical performance was Adequate	The feedback you received from your clinical instructor about your clinical performance was Good
The environment at this clinical facility in terms of stimulation was	The environment at this clinical facility in terms of stimulation was N/A	The environment at this clinical facility in terms of stimulation was Inadequate	The environment at this clinical facility in terms of stimulation was Somewhat lacking	The environment at this clinical facility in terms of stimulation was Adequate	The environment at this clinical facility in terms of stimulation was Good

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* 14. How often did you interact with other services for consultation, discussion, conferences, or rounds?

	N/A	Never	Seldom	Sometimes	Frequent
Medical services	Medical services N/A	Medical services Never	Medical services Seldom	Medical services Sometimes	Medical services Frequent
Nursing services	Nursing services N/A	Nursing services Never	Nursing services Seldom	Nursing services Sometimes	Nursing services Frequent
Occupational therapy services	Occupational therapy services N/A	Occupational therapy services Never	Occupational therapy services Seldom	Occupational therapy services Sometimes	Occupational therapy services Frequent
Recreational therapy services	Recreational therapy services N/A	Recreational therapy services Never	Recreational therapy services Seldom	Recreational therapy services Sometimes	Recreational therapy services Frequent
Social services	Social services N/A	Social services Never	Social services Seldom	Social services Sometimes	Social services Frequent
Vocational rehabilitation services	Vocational rehabilitation services N/A	Vocational rehabilitation services Never	Vocational rehabilitation services Seldom	Vocational rehabilitation services Sometimes	Vocational rehabilitation services Frequent
Psychological services	Psychological services N/A	Psychological services Never	Psychological services Seldom	Psychological services Sometimes	Psychological services Frequent
Classroom teacher services	Classroom teacher services N/A	Classroom teacher services Never	Classroom teacher services Seldom	Classroom teacher services Sometimes	Classroom teacher services Frequent
Orthotic services	Orthotic services N/A	Orthotic services Never	Orthotic services Seldom	Orthotic services Sometimes	Orthotic services Frequent
Prosthetic services	Prosthetic services N/A	Prosthetic services Never	Prosthetic services Seldom	Prosthetic services Sometimes	Prosthetic services Frequent
How often did you interact with staff members other than your clinical instructor?	How often did you interact with staff members other than your clinical instructor? N/A	How often did you interact with staff members other than your clinical instructor? Never	How often did you interact with staff members other than your clinical instructor? Seldom	How often did you interact with staff members other than your clinical instructor? Sometimes	How often did you interact with staff members other than your clinical instructor? Frequent
How often did your clinical instructor observe you performing patients treatments?	How often did your clinical instructor observe you performing patients treatments? N/A	How often did your clinical instructor observe you performing patients treatments? Never	How often did your clinical instructor observe you performing patients treatments? Seldom	How often did your clinical instructor observe you performing patients treatments? Sometimes	How often did your clinical instructor observe you performing patients treatments? Frequent
How often did you have an opportunity for communications/discussions with your clinical instructor?	How often did you have an opportunity for communications/discussions with your clinical instructor? N/A	How often did you have an opportunity for communications/discussions with your clinical instructor? Never	How often did you have an opportunity for communications/discussions with your clinical instructor? Seldom	How often did you have an opportunity for communications/discussions with your clinical instructor? Sometimes	How often did you have an opportunity for communications/discussions with your clinical instructor? Frequent
How frequently did you receive feedback from your clinical instructor about your performance?	How frequently did you receive feedback from your clinical instructor about your performance? N/A	How frequently did you receive feedback from your clinical instructor about your performance? Never	How frequently did you receive feedback from your clinical instructor about your performance? Seldom	How frequently did you receive feedback from your clinical instructor about your performance? Sometimes	How frequently did you receive feedback from your clinical instructor about your performance? Frequent
In your opinion, were the evaluations of your performance based on objective information?	In your opinion, were the evaluations of your performance based on objective information? N/A	In your opinion, were the evaluations of your performance based on objective information? Never	In your opinion, were the evaluations of your performance based on objective information? Seldom	In your opinion, were the evaluations of your performance based on objective information? Sometimes	In your opinion, were the evaluations of your performance based on objective information? Frequent

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* 15. How often did your clinical instructor:

	N/A	Never	Seldom	Sometimes	Frequent
Assign additional research or assignments	Assign additional research or assignments N/A	Assign additional research or assignments Never	Assign additional research or assignments Seldom	Assign additional research or assignments Sometimes	Assign additional research or assignments Frequent
Stimulate you to problem solve	Stimulate you to problem solve N/A	Stimulate you to problem solve Never	Stimulate you to problem solve Seldom	Stimulate you to problem solve Sometimes	Stimulate you to problem solve Frequent
Make you feel free to ask questions	Make you feel free to ask questions N/A	Make you feel free to ask questions Never	Make you feel free to ask questions Seldom	Make you feel free to ask questions Sometimes	Make you feel free to ask questions Frequent
Stimulate your thinking by questioning	Stimulate your thinking by questioning N/A	Stimulate your thinking by questioning Never	Stimulate your thinking by questioning Seldom	Stimulate your thinking by questioning Sometimes	Stimulate your thinking by questioning Frequent
Allow you to express your own ideas	Allow you to express your own ideas N/A	Allow you to express your own ideas Never	Allow you to express your own ideas Seldom	Allow you to express your own ideas Sometimes	Allow you to express your own ideas Frequent
Answer your questions in a straightforward and complete manner	Answer your questions in a straightforward and complete manner N/A	Answer your questions in a straightforward and complete manner Never	Answer your questions in a straightforward and complete manner Seldom	Answer your questions in a straightforward and complete manner Sometimes	Answer your questions in a straightforward and complete manner Frequent
Stimulate situations for practice	Stimulate situations for practice N/A	Stimulate situations for practice Never	Stimulate situations for practice Seldom	Stimulate situations for practice Sometimes	Stimulate situations for practice Frequent
Provide an adequate model to watch and imitate	Provide an adequate model to watch and imitate N/A	Provide an adequate model to watch and imitate Never	Provide an adequate model to watch and imitate Seldom	Provide an adequate model to watch and imitate Sometimes	Provide an adequate model to watch and imitate Frequent
Communicate readily and clearly with you	Communicate readily and clearly with you N/A	Communicate readily and clearly with you Never	Communicate readily and clearly with you Seldom	Communicate readily and clearly with you Sometimes	Communicate readily and clearly with you Frequent

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* 16. Rating scale for following 22 Questions

	No patients	One/Two patients	Three/Four patients	Five/Six patients	Seven or more patients
Amputation	Amputation No patients	Amputation One/Two patients	Amputation Three/Four patients	Amputation Five/Six patients	Amputation Seven or more patients
Arthritis and related collagen diseases	Arthritis and related collagen diseases No patients	Arthritis and related collagen diseases One/Two patients	Arthritis and related collagen diseases Three/Four patients	Arthritis and related collagen diseases Five/Six patients	Arthritis and related collagen diseases Seven or more patients
Burns and open legions	Burns and open legions No patients	Burns and open legions One/Two patients	Burns and open legions Three/Four patients	Burns and open legions Five/Six patients	Burns and open legions Seven or more patients
Cancer and benign tumors	Cancer and benign tumors No patients	Cancer and benign tumors One/Two patients	Cancer and benign tumors Three/Four patients	Cancer and benign tumors Five/Six patients	Cancer and benign tumors Seven or more patients
Cardio-pulmonary disorders	Cardio-pulmonary disorders No patients	Cardio-pulmonary disorders One/Two patients	Cardio-pulmonary disorders Three/Four patients	Cardio-pulmonary disorders Five/Six patients	Cardio-pulmonary disorders Seven or more patients
CP	CP No patients	CP One/Two patients	CP Three/Four patients	CP Five/Six patients	CP Seven or more patients
CVA	CVA No patients	CVA One/Two patients	CVA Three/Four patients	CVA Five/Six patients	CVA Seven or more patients
Cervical, dorsal, lumbar, strains	Cervical, dorsal, lumbar, strains No patients	Cervical, dorsal, lumbar, strains One/Two patients	Cervical, dorsal, lumbar, strains Three/Four patients	Cervical, dorsal, lumbar, strains Five/Six patients	Cervical, dorsal, lumbar, strains Seven or more patients
Developmental disability	Developmental disability No patients	Developmental disability One/Two patients	Developmental disability Three/Four patients	Developmental disability Five/Six patients	Developmental disability Seven or more patients
Fractures	Fractures No patients	Fractures One/Two patients	Fractures Three/Four patients	Fractures Five/Six patients	Fractures Seven or more patients
Head injury	Head injury No patients	Head injury One/Two patients	Head injury Three/Four patients	Head injury Five/Six patients	Head injury Seven or more patients
Joint/muscle injury	Joint/muscle injury No patients	Joint/muscle injury One/Two patients	Joint/muscle injury Three/Four patients	Joint/muscle injury Five/Six patients	Joint/muscle injury Seven or more patients
Joint replacements	Joint replacements No patients	Joint replacements One/Two patients	Joint replacements Three/Four patients	Joint replacements Five/Six patients	Joint replacements Seven or more patients
MD and related neuromuscular diseases	MD and related neuromuscular diseases No patients	MD and related neuromuscular diseases One/Two patients	MD and related neuromuscular diseases Three/Four patients	MD and related neuromuscular diseases Five/Six patients	MD and related neuromuscular diseases Seven or more patients
Neuropathy and myopathy	Neuropathy and myopathy No patients	Neuropathy and myopathy One/Two patients	Neuropathy and myopathy Three/Four patients	Neuropathy and myopathy Five/Six patients	Neuropathy and myopathy Seven or more patients
Parkinson's disease	Parkinson's disease No patients	Parkinson's disease One/Two patients	Parkinson's disease Three/Four patients	Parkinson's disease Five/Six patients	Parkinson's disease Seven or more patients
Psychiatric disorders	Psychiatric disorders No patients	Psychiatric disorders One/Two patients	Psychiatric disorders Three/Four patients	Psychiatric disorders Five/Six patients	Psychiatric disorders Seven or more patients
Scoliosis	Scoliosis No patients	Scoliosis One/Two patients	Scoliosis Three/Four patients	Scoliosis Five/Six patients	Scoliosis Seven or more patients
Spinal cord injury	Spinal cord injury No patients	Spinal cord injury One/Two patients	Spinal cord injury Three/Four patients	Spinal cord injury Five/Six patients	Spinal cord injury Seven or more patients
Debilitation (numerous medical problems)	Debilitation (numerous medical problems) No patients	Debilitation (numerous medical problems) One/Two patients	Debilitation (numerous medical problems) Three/Four patients	Debilitation (numerous medical problems) Five/Six patients	Debilitation (numerous medical problems) Seven or more patients
Other	Other No patients	Other One/Two patients	Other Three/Four patients	Other Five/Six patients	Other Seven or more patients

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* 17. Rating Scale for next Question

	A waste of time, would not recommend to others	Average	Time well spent, would definitely recommend to others
Based on your past experience in clinical education and your concept of the "ideal" clinical education experience, your experience at this site was:	Based on your past experience in clinical education and your concept of the "ideal" clinical education experience, your experience at this site was: A waste of time, would not recommend to others	Based on your past experience in clinical education and your concept of the "ideal" clinical education experience, your experience at this site was: Average	Based on your past experience in clinical education and your concept of the "ideal" clinical education experience, your experience at this site was: Time well spent, would definitely recommend to others

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* 18. What did you feel were the strengths of your academic preparation for this clinical experience?

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* 19. What did you feel were the weaknesses of your academic preparation for this clinical experience?

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* 20. During this clinical experience, if you were exposed to new subject matter areas not included in your previous academic curriculum, please describe.

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* 1. Please complete this evaluation after each clinical affiliation. Once completed, return this form to your ACCE as required.

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* 2. Did you select this facility for an affiliation?

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* 3. To gain knowledge about selecting this clinical affiliation, what sources did you use?

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* 4. During your affiliation at this site were the students who were affiliating:

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* 5. What special learning experiences were available to you during this affiliation?

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* 6. How many other students was your clinical instructor directly supervising?

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* 7. How many PT students were affiliating at the facility?

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* 8. How many other PTA students were affiliating at the facility?

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* 9. Describe the following information that was made available to you prior to your clinical education experience:

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* 10. Describe the amount of space that was available to you for:

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* 11. Describe the support services that were provided to you:

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* 12. Describe the support services that were not provided for you but available:

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* 13. Describe your orientation to this facility in:

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* 14. How often did you interact with other services for consultation, discussion, conferences, or rounds?

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* 15. How often did your clinical instructor:

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* 16. Rating scale for following 22 Questions

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* 17. Rating Scale for next Question

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* 18. What did you feel were the strengths of your academic preparation for this clinical experience?

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* 19. What did you feel were the weaknesses of your academic preparation for this clinical experience?

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* 20. During this clinical experience, if you were exposed to new subject matter areas not included in your previous academic curriculum, please describe.

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* 21. Describe how you would change the curriculum in view of the strengths and weaknesses you have noted above.

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* 22. Please comment on this experience.

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* 23. Please comment on your site visit with the program faculty.