CLINICAL CENTER INFORMATION FORM (CCIF)



CLINICAL CENTER INFORMATION FORM

Information for Academic Programs - Part I

I. Information About the Clinical Center

|Date (M/D/Y) |11/15/05 |

|Name of Clinical Center |Northwest Hospital |

|Address: Street |1550 N. 115TH |

|City |Seattle |State |WA |Zip |98133 |

|Facility Phone |206-368-1915 |Ext | |

|PT Department Phone |206-368-1915 |Ext. | |

|Fax Number |206-368-1924 |

|E-mail address |Cheryl.Reinhart@ or creinhar@ |

|Director of Physical Therapy |Pete Rigby |

|Center Coordinator of Clinical Education (CCCE) |Cheryl Reinhart |

|Person completing questionnaire |Cheryl Reinhart |

Complete the following table(s) if there are multiple sites that are part of the same health care system or practice. Copy this table before entering information if you need more space.

|Name of Clinical Center |Northwest Hospital Outpatient |

|Address: Street |10330 Meridan Ave. Nh |

|City |Seattle |WA | |98133 | |

|Facility Phone |206-368-6032 |Ext | |

|PT Department Phone |206-368-6032 |Ext. | |

|Fax Number |206-368-6035 |

|E-mail address |creinhar@ or Cheryl.Reinhart@ |

|Director of Physical Therapy |Pete Rigby |

|Center Coordinator of Clinical Education (CCCE) |Cheryl Reinhart |

|Please contact Cheryl for all information at 368-1915 | |

|Name of Clinical Center | |

|Address: Street | |

|City | |State | |Zip | |

|Facility Phone | |Ext | |

|PT Department Phone | |Ext. | |

|Fax Number | |

|E-mail address | |

|Director of Physical Therapy | |

|Center Coordinator of Clinical Education (CCCE) | |

|Name of Clinical Center | |

|Address: Street | |

|City | |State | |Zip | |

|Facility Phone | |Ext | |

|PT Department Phone | |Ext. | |

|Fax Number | |

|E-mail address | |

|Director of Physical Therapy | |

|Center Coordinator of Clinical Education (CCCE) | |

Clinical Center Accreditation/Ownership

|Yes |No | |Date of Last Accreditation/Certification |

|X | |1. Is your clinical center accredited/ certified? If no, go to #3. |See below |

| |2. If yes, by whom? | |

|X | | JCAHO |4/02 WILL BE COMING SPRING OF 2005 |

|X | | CARF |2/03 |

|X | | WA. State—DSHS |5/03 |

| | | CORF | |

| | | Other | |

| | 3. Who or what type of entity owns your facility/practice? |Hospital |

| | | |

| | | |

| | | |

Place the number 1 next to your facility's primary classification -- noted in bold type. Next, if appropriate, check up to 4 additional bold typed categories that describe other clinical centers associated with your primary classification. Beneath each of the 5 possible bold typed categories, check ( ) the specific learning experiences/settings that best describe that facility.

|1 |Acute Care/Hospital Facility | |Federal/State/County Health | |other |

| |univ. teaching hosp. | |VA |1 |Rehab/Subacute Rehab |

| |pediatric | |pediatric develop. ctr. |X |inpatient |

|X |cardiopulmonary | |adult develop. ctr. |X |outpatient |

|x |urban | |other | |pediatric |

| |suburban | |Home Health Care |X |adult |

| |rural | |agency |X |geriatric |

| |other | |contract service | |SCI |

|1 |Amubulatory Care/Outpatient | |Industrial Rehab. Facility— | |TBI |

| |pediatric | |Private Practice | |other |

|X |geriatric | |pediatric | |School/Preschool Program |

|X |sports PT | |geriatric | |school system |

|X |hospital satellite | |orthopedic | |preschool program |

| |pain center | |sports PT | |early intervention |

|X |Other-some industrial rehab—work hardening and | |podiatric | |other |

| |conditioning,, lymphedema, vestibular, and | | | | |

| |balance programs | | | | |

| |ECF/Nursing Home/SNF | |corporate practice | |Wellness/Prevention Program |

| | | |medicine for the arts | | |

5. If your clinical center provides inpatient care, what are the number of:

|X |Rehab beds—20---average census 10-12 |

| | |

|X |other beds (please specify) |ACUTE—189 |

| |total number of beds 219 |

| | |

| | |

II. Information About the Physical Therapy Service

|6. PT. Service hours |From: (a.m.) |To: (a.m.) |Comments |

|Monday |7:30 am |7:00 pm |OP hours 7:30-7:00 |

|Tuesday |7:30 am |7:00 pm |Hospital hours daily |

|Wednesday |7:30 am |7:00 pm |8:30-5:00 Sunday through Saturday|

|Thursday |7:30 am |7:00 pm | |

|Friday |7:30 am |7:00 pm | |

|Saturday |Closed |Closed | |

|Sunday |Closed |Closed | |

7. Indicate the number of full-time and part-time budgeted and filled position:

| |Full time budgeted |Full time filled |Part time budgeted |Part time filled |

|PTs |19 |18 |6 |6 |

|PTAs |3 |1 |0 |0 |

|Aides/Technicians |5 |3 |0 |0 |

|Administrative personnel |4 |4 |0 |0 |

|other | | | | |

8. Estimate an average number of patients per therapist treated per day in the PT department

|INPATIENT |OUTPATIENT |

|10-14 |Individual PT |12-14 |Individual PT |

|10-14 |Individual PTA |0 |Individual PTA |

|70-75 |Total PT service per day |160 |Total PT service per day |

9. Use the following code to indicate the patient population seen (by age) for inpatient and outpatient services, if appropriate. 1= Frequently 2= Occasionally 3= Rarely 4=Not available

|INPATIENT |OUTPATIENT |

|0 |< 1 (neonate) |0 | ................
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