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Ithaca College Clinical Education Survey
1. Clinical Instructor Information
*
1
. CI Name:
CI Name:
*
2
. Facility Name:
Facility Name:
3
. Student Name:
Student Name:
*
4
. 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)
5
. What is your entry level degree?
What is your entry level degree?
BS
MS
DPT
6
. What is your highest degree?
What is your highest degree?
MS
DPT
PhD
EdD
DSc
Other
7
. Number of years as a clinician.
Number of years as a clinician.
< 1
1 - 5
6 - 10
11 - 15
16 - 20
> 20
8
. Number of years as a CI.
Number of years as a CI.
< 1
1 - 5
6 - 10
11 - 15
16 - 20
> 20
9
. APTA Credentialed?
APTA Credentialed?
No
Level 1
Level 2
10
. Specialty certifications:
Specialty certifications:
CCS
CSCS
ECS
GCS
McKD
NCS
OCS
PCS
SCS
Other (please specify)
11
. APTA Member?
APTA Member?
Yes
No
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