Doctor of Physical Therapy Program
Clinical Site/Clinical Instructor Interest Form
Please fill out this form if you are interested in discussing the possibility of becoming an affiliated clinical site and/or clinical instructor for DPT students. We provide Continuing Education credit and eventually plan to offer education and training for future clinical educators. Please let us know the following details so we may contact you. Thank you for your support!
Date
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Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Title
*
Credentials
*
Work Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Site Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Predominant setting type a student could be offered at site (choose all that apply)
*
Inpatient General
Inpatient/Outpatient General
Inpatient Acute
Inpatient Sub-Acute/SNF/LTC
Inpatient ICU
Inpatient Pediatrics
Inpatient Rehab - Neuro
Inpatient Rehab - Pulmonary
Inpatient Rehab - General
Outpatient General
Outpatient Orthopedics
Outpatient Orthopedics/Sports
Outpatient Orthopedics/Pelvic Health
Outpatient Pediatrics - School Based
Outpatient Pediatrics - Facility Based
Outpatient Sports
Outpatient Pelvic Health
Outpatient Hand
Outpatient Home Health
Outpatient Rehab
Other
Does your site have multiple locations at this time?
*
Yes
No
Please indicate the preference of student's educational level in the DPT program, in order for the student to attend your site for a clinical rotation.
*
Year 2 (first clinical)
Year 3 (second clinical)
Year 3 (terminal clinical)
Will you serve as a Clinical Instructor (CI)? (If yes, then go to next 2 questions)
*
Yes
No
Are you credentialed from the APTA as a Clinical Instructor (select one):
No, Not credentialed through APTA at this time.
Yes, credentialed CI with completion of APTA Level I Basic Course
Yes, credentialed with CI with completion of APTA Level II Advanced course
Have you completed the APTA CPI 3.0 training (new in Fall of 2023) online at the APTA website?
Yes
No
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