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Site Manager Site Survey —Site: Tufts Medical CenterSection TitleLastUpdateCCCE Sign Off11/24/15 02:31 PMCCCE Sign OffCCCE Sign Off:Click the box below to indicate that you have reviewed all sections of your clinical site survey.This survey has been reviewed.Information For the Academic ProgramInformation For the Academic ProgramPerson Completing CSIF:Rennie Gilman, PT, DPTE-mail address of person completing CSIF:rgilman1@tuftsmedicalcenter.orgName of Clinical Center (Note: To correct the name of your site, as it appears in both CSIF Web and CPI Web, update it in this field).:Tufts Medical CenterStreet AddressAddress:800 Washington StreetBox 419City:BostonState:MAPostal Code:02111Facility PhonePhone Number:(617) 636-5632Ext:PT Department PhonePhone Number:(617) 636-5632Ext:PT Department FaxPhone Number:(617) 636-4722Clinical Center Web Address:www.tuftsmedicalcenter.orgDirector of Physical Therapy:Mike Foley, RTRCenter Coordinator of Clinical Education (CCCE) / Contact Person:Kristin Boyd, PT, DPT01/08/17 08:08 PMAction
CCCE / Contact Person Phone:(617) 636-5632CCCE / Contact Person E-mail:KSchram@tuftsmedicalcenter.orgSection Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Information About the Corporate/Healthcare Systems Organization01/08/17 08:08 PMInformation About the Corporate/Healthcare Systems OrganizationIf your facility is part of a larger corporation or has multiple sites or clinical centers, include the contact information for the corporate/healthcare system organization.Corporate/Healthcare System Organization:Tufts Medical CenterContact Name:Kristin Boyd, PT, DPTAddressAddress:800 Washington StreetBox 419City:BostonState:MAPostal Code:02111PhonePhone Number:(617) 636-5632Ext:FaxPhone Number:(617) iation Agreement Contract FulfillmentContact Person:Kristin Boyd, PT, DPTSection Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Clinical Site Accreditation/Ownership01/08/17 08:08 PMClinical Site Accreditation/OwnershipWhich of the following best describes the ownership category for your clinical site? (check all that apply)Corporate/Privately OwnedGovernment AgencyHospital/Medical Center OwnedNonprofit AgencyPT OwnedPT/PTA Owned
Physician/Physician Group OwnedOtherSection Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Clinical Site Primary Classification01/08/17 08:08 PMClinical Site Primary ClassificationChoose the category that best describes how your facility functions the majority ( 50%) of the time.Acute Care/Inpatient Hospital FacilityIf appropriate, check ( ) up to four additional categories that describe the other clinical centers associated with your facility.Acute Care/Inpatient Hospital FacilityAmbulatory Care/OutpatientECF/Nursing Home/SNFFederal/State/County HealthHome HealthIndustrial/Occupational Health FacilityMultiple Level Medical CenterPrivate PracticeRehabilitation/Sub-acute RehabilitationSchool/Preschool ProgramWellness/Prevention/Fitness ProgramOtherSection Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Clinical Site Location01/08/17 08:08 PMClinical Site LocationWhich of the following best describes your clinical site’s locationUrbanSection Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Affiliated PT and PTA Educational Programs01/08/17 08:08 PMAffiliated PT and PTA Educational ProgramsList all PT and PTA education programs with which you currently affiliate.Program NameCityStatePT / PTABay State CollegeBostonMAPTABoston UniversityBostonMAPTMGHIHPBostonMAPTNortheastern UniversityBostonMAPTSimmons CollegeBostonMAPTUniversity of Massachusetts - LowellLowellMAPTUniversity of VermontBurlingtonVTPTEmory UniversityAtlantaGAPTThe George Washington UniversityWashingtonDCPTSelect the program(s) your site is currently affiliated with:By A-Z:AnyBy State:AnyIf not found in the list, please enter the program information here:Program Name:City:State:ABPT / PTA:PTAddClear
ACCE Demo University,ACCE Demo University,ACCE Demo University,ACCE PTA Demo,ASA College, FLSectionSign Off:ATStill Universityof Health Sciences, AZAcademyNursingHealth Occupations,FLClick theforboxbelow andto indicateyou have reviewedand finished with this section of the survey.Adventist University of Health Sciences, FLThis Statesectionhas beenALcompleted.AlabamaUniversity,Albany State University-Darton College, GAInformation About the Clinical Teaching Faculty01/12/17 05:27 PMAllegany College of Maryland, MDAltanta Technical College, GAInformation About the Clinical Teaching FacultyAlvernia University, PAAmarillo College, TXAbbreviated Resume for Center Coordinators of Clinical Education - Please update as each new CCCE assumes this position.American Career College, CAAmerican International College, MAName:Anderson University,Kristin mail Address/ CPI2Angelo State University, TXKSchram@tuftsmedicalcenter.orgAnoka Ramsey Community College, MNPresent Position (Title, Name of Facility):Arapahoe Community College, COSeniorUniversity,Physical Therapistand Center Coordinator of Clinical Education, Tufts Medical CenterArcadiaPAArkansas State University, ARNo. of Years as the CCCEArkansas State University PTA, ARArkansas1Tech University - Ozark Campus, ARAtenas College, PRNo. ofTechnicalYears ofCollege,ClinicalGAPracticeAthensAtlanta Technical College, GA6Augusta University, GAAustinCollege, TXNo. ofCommunityYears of ClinicalTeachingAzusa Pacific University, CA4Baker College of Allen Park, MIBaker College of Auburn Hills, MINo. of Years Working at this SiteBaker College of Flint, MI5Baker College of Muskegon, MIBaltimore City Community College, MDCheck all that apply:Baylor University, TXBellarmine University,KYPTBelmont University, TNBerkshire Community College, MABishop State Community College, ALLicensing/Registration StatusBlack Hawk College, ILLicensed/RegisteredBlackhawk Technical College, WIBlinn College, TXState of Licensure/RegistrationBossier Parish Community College, LAMA School - Columbus, OHBradfordBradford School - Pittsburgh, PALicense/Registration Number:Bradley University, IL21493Brenau University, GABriar Cliff University, IABrighamUniversity- Rexburg,ID DegreeHighestYoungEarnedPhysicalTherapyBrookline College, AZDoctor in Physical TherapyBroome Community College, NYBroward College, FLHighest Earned DegreeBrown Mackie College, INProfessional Doctor in Physical TherapyBryant & Stratton College - Orchard Park, NYBryant & Stratton College - Parma, OHAPTA Credentialed CIBryant & Stratton College - Syracuse, NYYesNo- Wauwatosa, WIBryant& Stratton CollegeButler County Community College, PAAPTA Advanced Credentialed CICBD College, CAYesCommunity CollegeNo and Technical Institute, NCCaldwellCalifornia State University, Fresno, CAOther CI CredentialingCalifornia State University, Long Beach, CAYes State University,No Northridge, CACaliforniaPTA
ABPTS Certified Clinical Specialist (Check all that apply)OCSGCSPCSNCSCCSSCSECSWCSAPTA Recognition of Advanced Proficiency for PTAs (Check all that scularGeriatricPediatricsIntegumentaryOther credentials:Summary of College and University Education(Start with most current)Institution:MGH Institute of Health ProfessionalsPeriod of Study(If the user is currently enrolled, please type in the word 'CURRENT' into the box labeled 'To'.)From 2008— To 2011Major:Physical TherapyDegree:Doctorate in Physical TherapySummary of Primary Employment(For current and previous four positions since graduation from college; start with most current)Employer:Tufts Medical CenterPosition:Physical TherapistPeriod of Employment(If the user is currently employed, please type in the word 'CURRENT' into the box labeled 'To'.)From 12/01/12— To CURRENTContinuing Professional Preparation Related Directly to Clinical Teaching Responsibilities(for example, academic for credit courses [dates and titles], continuing education [courses and instructors], research, clinical practice/expertise, etc. in the last three(3) years)Course:Provider/Location:DateSection Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Clinical Instructor Information01/20/17 12:54 PM
Clinical Instructor InformationProvide the following information on all PTs or PTAs employed at your clinical site who are CIs.CI Name Followed By CredentialsCI UsernameBlatt, Joshjblatt@tuftsmedicalcenter.orgBoneparth, Marie Kmboneparth@tuftsmedicalcenter.orgBoucher, MeganMBoucher1@tuftsmedicalcenter.orgBoudouvas, Abbey JAKole@tuftsmedicalcenter.orgBoyd, Kristin Mkboyd3@tuftsmedicalcenter.orgBreadmore, Kyliekbreadmore@tuftsmedicalcenter.orgCampbell, Kathleen Mkcampbell5@tuftsmedicalcenter.org(Connie) Sullivan, Concetta BCSullivan7@tuftsmedicalcenter.orgde Jong, Kristinkdejong@tuftsmedicalcenter.orgFallano, MaryMfallano@tuftsmedicalcenter.orgFasano, AmandaAFasano@tuftsmedicalcenter.orgGuerin, Nicole Anguerin@tuftsmedicalcenter.orgHaines, Linda Mlhaines1@tuftsmedicalcenter.orgJablonski, Janellejjablonski@tuftsmedicalcenter.orgKajen, Julia Njkajen@tuftsmedicalcenter.orgKiesz, Marisol MMkiesz@tuftsmedicalcenter.orgKlinkenberg, Lisalklinkenberg@tuftsmedicalcenter.orgKo, Cathycko@tuftsmedicalcenter.orgKras, AllisonAKras@tuftsmedicalcenter.orgKrasney, Sara Jskrasney@tuftsmedicalcenter.orgLai, Carmenclai@tuftsmedicalcenter.orgLebeche, KhaoulaKlebeche@tuftsmedicalcenter.orgLivolsi, Rachel Erlivolsi@tuftsmedicalcenter.orgMortali, Meaghan EMMortali@tuftsmedicalcenter.orgPoon, Eileenepoon@tuftsmedicalcenter.orgAdd New CIActionsPrevious 1 2 NextDisplaying Clinical instructor 1 - 25 of 30 in totalSection Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Clinical InstructorsClinical InstructorsWhat criteria do you use to select clinical instructors? (Check all that apply)01/12/17 05:27 PM
APTA Clinical Instructor CredentialingCareer ladder opportunityCertification/training courseClinical competenceDelegated in position descriptionDemonstrated strength in clinical teachingNo criteriaOther (not APTA) clinical instructor credentialingTherapist initiative/volunteerYears of experienceOtherHow are clinical instructors trained? (Check all that apply)1:1 individual training (CCCE:CI)APTA Clinical Instructor Education and CredentialingProgramClinical center inservicesContinuing education by academic programNo trainingOther (not APTA) clinical instructor credentialing programAcademic for-credit courseworkContinuing education by consortiaProfessional continuing education (e.g., chapter, CEUcourse)OtherSection Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Information About the Physical Therapy Service11/24/15 02:29 PMInformation About the Physical Therapy ServiceNumber of Inpatient Beds For clinical sites with inpatient care, please provide the number of beds available in each of the subcategories listed below: (If this does not applyto your facility, please skip and move to the next table.)Acute care:415Psychiatric center:Intensive care:Rehabilitation center:Step down:Subacute/transitional care unit:Extended care:Other specialty centers:Total Number of Beds:415Section Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Number of Patients/Clients11/24/15 02:29 PMNumber of Patients/ClientsEstimate the average number of patient/client visits per day:Inpatient10Outpatient12Individual PT:Individual PT:Student PT:Student PT:Individual PTA:Individual PTA:Student PTA:Student PTA:PT/PTA Team:10Total patient/client visits per day:Section Sign Off:PT/PTA Team:12Total patient/client visits per day:
Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Patient/Client Lifespan and Continuum of Care11/24/15 02:29 PMPatient/Client Lifespan and Continuum of CareIndicate the frequency of time typically spent with patients/clients in each of the categories:Patient Lifespan0-12 years1% - 25%13-21 years1% - 25%22-65 years26% - 50%Over 65 years51% - 75%Continuum of CareCritical care, ICU, acute76% - outpatient1% - 25%Home health/hospice0%Wellness/fitness/industry1% - 25%Section Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Patient/Client Diagnoses11/24/15 02:29 PMPatient/Client DiagnosesIndicate the frequency of time typically spent with patients/clients in each of the categories:Musculoskeletal51% - 75%Which Musculoskeletal sub-categories are available to the student:Acute injuryAmputationArthritisBone disease/dysfunctionConnective tissue disease/dysfunctionMuscle disease/dysfunctionMusculoskeletal degenerative diseaseOrthopedic surgeryOtherNeuro-muscular
26% - 50%Which Neuro-muscular sub-categories are available to the student:Brain injuryCerebral vascular accidentChronic painCongenital/developmentalNeuromuscular degenerative diseasePeripheral nerve injurySpinal cord injuryVestibular disorderOtherCardiovascular-pulmonary1% - 25%Which Cardiovascular-pulmonary sub-categories are available to the student:Cardiac dysfunction/diseaseFitnessLymphedemaPeripheral vascular dysfunction/diseasePulmonary dysfunction/diseaseOtherOpen woundsScar formationCognitive impairmentGeneral medical conditionsGeneral surgeryOncologic conditionsOrgan transplantWellness/PreventionIntegumentary1% - 25%Which Integumentary sub-categories are available to the student:BurnsOtherOther (May cross a number of diagnostic groups)26% - 50%Which other sub-categories are available to the student:OtherSection Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Staffing11/24/15 02:29 PMStaffingFull-time BudgetedPTs20PTAsAides/TechsPart-time Budgeted5Current Staffing25222299Other:OTSection Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Information About the Clinical Education ExperienceInformation About the Clinical Education ExperienceSpecial Programs/Activities/Learning OpportunitiesPlease check all special programs/activities/learning opportunities available to students.11/24/15 01:56 PM
AdministrationAquatic TherapyAthletic Venue CoverageBack SchoolBiomechanics LabCardiac RehabilitationCommunity/Re-entry ActivitiesCritical Care/Intensive CareDepartmental AdministrationEarly InterventionEmployee InterventionEmployee Wellness ProgramGroup Programs/ClassesHome Health ProgramIndustrial/Ergonomic PTInservice Training/LecturesNeonatal CareNursing Home/ECF/SNFOrthotic/Prosthetic FabricationPain Management ProgramPediatric - Classroom Consultation EmphasisPediatric - Cognitive Impairment EmphasisPediatric - Developmental Program EmphasisPediatric - GeneralPediatric - Musculoskeletal EmphasisPediatric - Neurological EmphasisPrevention/WellnessPulmonary RehabilitationQuality Assurance/CQI/TQMRadiologyResearch ExperienceScreening/PreventionSports Physical TherapySurgery (observation)Team Meetings/RoundsVestibular RehabilitationWomen's Health/OB-GYNWork Hardening/ConditioningWound CareOtherSpecialty ClinicsPlease check all specialty clinics available as student learning experiences.ArthritisBalanceDevelopmentalFeeding clinicHand clinicHemophilia clinicIndustryNeurology clinicOrthopedic clinicPain clinicPreparticipation sportsProsthetic/orthotic clinicScoliosisScreening clinicsSeating/mobility clinicSports medicine clinicWellnessWomen's healthOtherPlease explain:Health and Educational Providers at the Clinical SitePlease check all health care and educational providers at your clinical site students typically observe and/or with whom they interact.AdministratorsAlternative therapiesAthletic trainersAudiologistsDietitiansEnterostomal / wound specialistsExercise physiologistsFitness professionalsHealth information technologistsMassage therapistsNursesOccupational therapistsPhysician assistantsPhysiciansPodiatristsProsthetists / orthotistsPsychologistsRespiratory therapistsSocial workersSpecial education teachersSpeech/language pathologistsStudents from other disciplinesStudents from other physical therapy education programsTherapeutic recreation therapistsVocational rehabilitation counselorsOtherPlease explain:PTA, CO-OPSection Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.This section has been completed.Availability of the Clinical Education ExperienceAvailability of the Clinical Education ExperienceIndicate educational levels at which you accept PT and PTA students for clinical experiences (Check all that apply).11/24/15 01:56 PM
Physical TherapistFirst Experience:Full daysHalf daysOtherHalf daysOtherInternship (6 months or longer)Specialty experienceHalf daysOtherHalf daysOtherPhysical TherapistIntermediate Experiences:Full daysPhysical TherapistFinal ExperienceOtherPhysical Therapist AssistantFirst Experience:Full daysPhysical Therapist AssistantIntermediate Experiences:Full daysPhysical Therapist AssistantFinal ExperienceOtherPTIndicate which months you will accept students for any single full-time (36 hrs/wk) clinical ustSeptemberOctoberNovemberDecemberIndicate which months you will accept students for any one part-time ( 36 hrs/wk) clinical ustSeptemberOctoberNovemberDecemberPTAIndicate which months you will accept students for any single full-time (36 hrs/wk) clinical ustSeptemberOctoberNovemberDecemberIndicate which months you will accept students for any one part-time ( 36 hrs/wk) clinical ustSeptemberOctoberNovemberDecemberAverage number of PT students affiliating per year.:12Average number of PTA students affiliating per year.:2Is your clinical site willing to offer reasonable accommodations for students under ADA?YesPlease explain:No
What is the procedure for managing students whose performance is below expectations or unsafe?:Explain what provisions are made for students if the clinical instructor is ill or away from the clinical site. br/ (Answer if the clinical center employs only one PT or PTA.):Section Sign Off:Click the box below to indicate you have reviewed and finished with this section of the survey.ClinicalThisSite'ssectionLearninghas beenObjectivescompleted.and Assessment11/24/15 01:56 PMClinical Site's Learning Objectives and AssessmentDoes your clinical site provide written clinical education objectives to students?YesNoAre all professional staff members who provide physical therapy services acquainted with the clinical site's learning objectives?YesNoWhen do the CCCE and/or CI typically discuss the clinical site's learning objectives with students? (Check all that apply)At end of clinical experienceAt mid-clinical experienceBeginning of the clinical experienceDailyWeeklyOtherIndicate which of the following methods are typically utilized to inform students about their clinical performance? (Check all that apply)As per student request in addition to formal and ongoingwritten & oral feedbackWritten and oral mid-evaluation
Kristin Boyd, PT, DPT. CCCE / Contact Person Phone: (617) 636-5632 CCCE / Contact Person E-mail: KSchram@tuftsmedicalcenter.org . Alvernia University, PA Amarillo College, TX American Career College, CA American International College, MA Anderson U
