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Ithaca College Clinical Education Survey
1. Clinical Instructor Information
*
1
. CI Name:
CI Name:
2
. You have earned Continuing Education Hours for your work as a CI! Please enter your email address below so that we may send you a certificate.
You have earned Continuing Education Hours for your work as a CI! Please enter your email address below so that we may send you a certificate.
3
. Please add your license number here.
Please add your license number here.
*
4
. Facility Name:
Facility Name:
5
. Student Name:
Student Name:
*
6
. Clinical Education Course:
Clinical Education Course:
I (May 8 weeks)
II (Jan 8 weeks)
III (Nov 7 weeks)
IV (May 12 weeks)
V (May 6 weeks)
VI (July 6 weeks)
7
. What is your entry level degree?
What is your entry level degree?
BS
MS
DPT
8
. What is your highest degree?
What is your highest degree?
MS
DPT
PhD
EdD
DSc
Other
9
. Number of years as a clinician.
Number of years as a clinician.
< 1
1 - 5
6 - 10
11 - 15
16 - 20
> 20
10
. Number of years as a CI.
Number of years as a CI.
< 1
1 - 5
6 - 10
11 - 15
16 - 20
> 20
11
. APTA Credentialed?
APTA Credentialed?
No
Level 1
Level 2
12
. Specialty certifications:
Specialty certifications:
CCS
CSCS
ECS
GCS
McKD
NCS
OCS
PCS
SCS
Other (please specify)
13
. APTA Member?
APTA Member?
Yes
No
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