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_________________________________