University of Delaware
Department of Physical Therapy
Service Learning/Volunteer Request Form
Student Name: Pre-approved MS Clinic
Categories of Service (circle one): Volunteerism, Health and Wellness Promotion, Diversity,
Promotion of the Physical Therapy Profession
Location: UDPT Department- MS Clinic
Dates (if known): 3 times each in spring and fall semester
Estimate of amount of time in hours you will devote to this service or volunteer work: _~3 hours
each session
Briefly describe and justify the nature of the service or volunteer experience: The MS Clinic is a
voluntary assessment clinic that utilizes multiple professionals in one locations to offer a 1x
assessment of function, psychosocial health and health promotion activities for people with MS.
The clinic is open to all patients with MS (they are asked to join the Delaware MS Society if they
are not already members) regardless of race, religion, sex, or financial status.
Faculty Contact: Cathy Ciolek
Please list the course/s Name and the objectives of a particular course which you have completed or
are presently taking that you feel will be applicable to your proposed experience (courses and
objectives can be found on our web-site)
Course : PHYT 804
Applicable Objectives: Demonstrate an ability to develop and safely
implement a treatment program that incorporates aspects of each therapeutic approach and that is
consistent with the patient’s evaluation and prognosis.
Course : PHYT 804
Applicable Objectives:_Accurately and objectively identify, retrieve,
analyze, and interpret patient information (gathered from patient, significant others, medical
records, direct PT tests and procedures) in order to assess patient's physical therapy needs, i.e.,
determine needs of patient or refer to other services.
Course : PHYT 804
Applicable Objectives: Design a comprehensive home treatment
program that includes a consideration of the influence of environmental constraints on patient
performance of ADLs and teach the patient and family how to implement the program.
Course : PHYT 809
Applicable Objectives: Document the impact of chronic disease and
disability on psychosocial development and the importance of considering these issues in decision
making and planning.
Course: PHYT 801
Applicable Objectives: the ability to educate patients and their
families regarding the impact of common medical conditions.
Approvers Name: ____Cathy Ciolek, PT, DPT, GCS_____________________
Approvers Signature: _____Cathy Ciolek, PT, DPT, GCS_________________________________