Clinical Physiology (CLPH):
Clinic Field Experience Guidelines
(EXSC 493)
Please initial each component to verify completion.
This initialed checklist serves as the obligatory cover page for the document file.
_____ CAPS report reviewed by student and academic advisor/program
director to ensure all courses required for the major are completed
satisfactorily.
_____ Discuss field experience interests and possibilities with CLPH
Faculty Coordinator (Dr. Nethery).
_____ Complete Pre-registration File Initiation Form (in this packet) _____ Complete (typed) the Learning Agreement and Release Form
(template provided) for each field experience site. This template assumes
completion of a 15-credit experience at the same location in a single quarter.
_____ Generate Objectives and Activities (see examples provided)
_____ Complete the Harassment Training and attach certificate of
completion.
_____ Obtain Liability Insurance (READ enrollment and payment instructions
carefully). Attach a copy of the insurance certificate.
_____ Attach a copy of your driver’s license.
_____ Learning Agreement signed by clinic supervisor.
_____ Learning Agreement signed by student.
Additional records required by hospital-medical clinic agreements
must
be completed and on file. These typically include Immunization records, Drug
Screening, Criminal History, HIPPA and Blood Borne pathogen certifications, CPR
certificate, other requirements specified in affiliation agreement contracts) –
Specific details are available from the CLPH Faculty Coordinator.
_____ ALL forms/documents paper clipped together in order noted above,
and submitted to CLPH Faculty Coordinator for Field Experience. A by-permit registration will be completed only after all documents are completed,
signed, and approved by the Field Experience Coordinator.
Clinical Physiology File Initiation Form
Name (First, Last):
SID:
Mailing Address:
Email:
Major/Minor:
Quarter for Field Experience:
Quarter Graduating:
Field Experience Facility:
Phone:
Description and Purpose:
The Field Experience is a requirement for the Bachelor of Science degree in Clinical Physiology and
students are eligible to undertake this experience upon satisfactory completion of program course
work. You must communicate with the Clinical Physiology Field Experience Coordinator prior to
initiating specific discussions with any potential sites. Previous volunteer or work experiences cannot
be used to satisfy Field Experience hours and credits. The Field experience may be a paid or a
volunteer position – this is dependent upon the facility.
The purpose of the Field Experience is to gain exposure through immersion into a professional-health
care setting. Such settings typically involve the evaluation, prescription, monitoring, and promotion of
behaviors related to personal health and wellbeing in diseased, aged, or injured populations. This is
an active-learning experience where skills developed and knowledge learned in preparatory courses
is applied in real world settings.
The field experience is under the direct supervision of certified and licensed professionals and the
student is expected to adhere to the same professional requirements as an employed member of the
clinic. A minimum of 12 credits of Field Experience is required for graduation - this corresponds to a
total in-facility time of 360 hours (30hrs/credit). Up to 15 credits (450hrs) can be registered for in a
single quarter. Full-time tuition remains constant up to 18 credits. Field experience can be repeated
for credit with a total of 20 credits eligible to count towards the 180-credit bachelor’s degree
requirement on the institution.
The Field Experience can be divided equally between two separate facilities. This experience may also
be spread over two quarters.
Should the Field Experience be terminated at any time prior to completion, the student and the clinic
supervisor must immediately contact the CLPH Field Experience Coordinator. The reason(s) for this
action should be in writing and should be specific. Any supporting documentation should accompany
this request.
The student should be aware of all university and on-site location policies and procedures regarding
Field Experiences prior to beginning.
Field Experience Locations:
Field Experience sites vary considerably and include clinics and other healthcare facilities such as
physical therapy, cardiopulmonary rehabilitation, occupational therapy, chiropractic medicine,
medicine, physicians assistants, nursing, sports medicine-athletic injury, diabetes/metabolic disorder
centers, cardiac diagnostics, dependent care facilities, ……….
Clinic Supervisor/Preceptor Responsibilities:
1. Guide and critically evaluate student learning and progress.
2. Be the organization’s contact person for the university.
3. Evaluate the student
- input from others may be solicited.
Objectives and Activities:
A minimum of three (3) objectives must be prepared and, for each, between 2 and 4 activities are
required. The following format for describing objectives and activities MUST be followed precisely.
Objectives:
An objective (labeled I, II, III, ...) is a broad statement that is conceptually based. The specific concept
is usually preceded by:
To obtain a better understanding of.........
To gain a greater appreciation for .........
To become more competent at .........
Learning Activities:
A list of specific activities (labeled a, b, c, ...) that relate to each objective.
Example – Cardiac Diagnostics/Rehabilitation:
Objective I: To obtain a better understanding of diagnostic tools that assess coronary disease and
cardiac problems.
Learning Activities:
Ia. Observe and participate as permitted in EKG exercise stress testing
Ib. Observe echocardiography and angiogram procedures
Ic. Observe open-heart by-pass surgery
Example - Physical Therapy:
Objective I: To obtain a better understanding of modalities used to treat soft-tissue injury.
Learning Activities:
Ia. Observe and participate as permitted in administration of thermal modalities
Ib. Observe and participate as permitted in administration of ultrasound
Ic. Observe and participate as permitted in administration of e-stim modalities
Evaluation:
The Field Experience is graded on a satisfactory/unsatisfactory basis using the following criteria:
(i) Mid-point and end-of-quarter journal log submissions
(ii) Final report
(iii) Mid-point and final site-supervisor evaluations
(iv) Mid-point and final student evaluations
Journal logs and the final report are sent as email attachments to the CLPH Field Experience
Coordinator.
Mid-point and final evaluations are sent as email attachments from the CLPH Field Experience
Coordinator.
Journal Log Format/Guidelines:
A journal summarizing weekly activities is required and must be formatted as follows:
Title page:
Agency name …… Address …… Phone number …… Student name …… Site supervisor name and email
address …… Site website listing …… CWU Field experience supervisor name.
Weekly entries:
• Dates …… Hours worked each day …… Cumulative hours for the week …… Cumulative hours for the
internship to date … Summary of experiences of the week … Reflective comments on their value
The Final Report – must include the following four section headings in sequence
1. Site Overview:
A general description of the facility (location, size, facilities,...)
The mission of the site
The range and general descriptions of clientele of the site
The staff (who, qualifications, specific roles, .........)
Reports or special projects you completed.
2. Learning objectives:
Address each of the learning objectives listed on the learning agreement.
Describe the experiences you had that assess whether the objectives were met.
Describes any activities undertaken that were outside of the established objectives.
3. Field Experience Conclusion:
Provide both qualitative and quantitative evaluations of the Field Experience as part of
academic preparation for a career in the profession.
4. Reflective Overview:
Provide a reflective overview of the academic program for Clinical Physiology at CWU.
Identify specific classes and practical experiences beneficial in preparing for the “real world”.
Note program components than were not particularly valuable for your experience.
CLINICAL PHYSIOLOGY FIELD EXPERIENCE LEARNING AGREEMENT
PURSER HALL - Central Washington University
400 E. University Way, Ellensburg, WA 98926-7572
509-963-1912, Fax 509-963-1989, https://www.cwu.edu/health-science/bachelor-science-clinical-physiology
This agreement must be completed (TYPED) and approved by ALL signatories before permission codes for registration
can be provided. Additional requirements and instructions pertaining to this agreement are in these guidelines.
(Revised: Fall Quarter - 2016)
Office Use Only: Registration Date _________ Course _____________________ Course # ___________
STUDENT INFORMATION
Name: (First, Middle I., Last) Peta Jane Smith Major: Clinical Physiology
CWU I.D. Number: 00022210
Phone: (111) 555-1111
Mailing Address during Field Experience: 1234 Upside
Lane
City: Hanger State: WA Country*: USA Zip: 99999 CWU email: smithpj@cwu.edu
Cumulative Credits: 176
Current Cumulative GPA: 3.56
Quarter to Be Registered: Fall 2016
Expected Graduating Qtr/Yr: Fall 2016
Have you signed the Student Field Experience Release Form? Yes
Have you completed the Sexual Harassment Training? Yes
https://cwu.adobeconnect.com/_a787149012/p1znfe5ex92/)
Are you an International Student with a F1 visa? Yes
No
No
Date July 15, 2016
Attach Certificate of Completion to this form.
No
International students on a F1 visa must obtain the signature of the International Student Advisor
*Please take this completed agreement to Study Abroad & Exchange Programs located in room 101 in the International
Center if the experience will take place outside of the United States. Additional paperwork will be required.
PLACEMENT INFORMATION
Field Experience Facility: OrthoPT Web URL: www.orthopt.com Student’s Position Title: Intern
Facility Category: Non-Profit
For Profit
Government
Education
Facility Mailing Address: (POB or Street) 1234 Main St City: Bigville State: WA Zip: 99991 Country: USA
Facility Location if Different from Mailing Address: n/a
Clinic Supervisor/Preceptor: Janine Watson Title: Physical Therapist
CWU Alumnus/a Yes
No
Clinic Phone: (111) 123-4567 Clinic Supervisor email: watsonj@orthopt.com
Clinic Hours Per Week:42
Number of Weeks:11
Paid ___Unpaid X Wage Per Hour: n/a
Total Hours: 450
Other Compensation: (stipend, meals, lodging, mileage) n/a
Starting Date: September 20, 2016 Completion Date December 6, 2016
EMERGENCY CONTACT INFORMATION
Name: Mona Smith Relationship to Intern: Parent
Emergency Contact Address: 2222 Dog St City: Wooftaville State: WA Zip: 99993
Phone: (509)111-6789
Academic Details:
Course Prefix: EXSC
Email: smithmom@aol.com
Course Number: 493 Number of Credits: 15
Field Experience Coordinator: Dr. Nethery Department / Office Phone: (509) 963-1912 / (509) 963-1940
Email Address:netheryv@cwu.edu Department Fax Number(509) 963-1848
Academic Requirements:
Mid-Term Journal Log Due: Due at mid-point
Final Journal Log Due: Due upon completion of hours
Final Report Due: Due upon completion of hours
Number of Email Contacts: 2+
Other Notes: All journal logs, final reports, and evaluations submitted as email attachments to Field Experience Coordinator
Faculty Coordinator Clinic Site Visits: Upon arrangement
Field Experience Overview: Example:
Gain insight and experience in a rehabilitation clinic with intent to gain admission to and to pursue a career as a physical therapist
OBJECTIVES & ACTIVITIES:
SEE EXAMPLES OF OBJECTIVES AND ACTIVITIES IN THIS GUIUDELINES PACKET – REPLICATE THE FORMAT AND LANGUAGE
Objective I:
Activities I(a)
I(b)
I(c)
Objective II:
Activities II(a)
II(b)
II(c)
Objective III:
Activities III(a)
III(b)
III(c)
Student Responsibilities
1. Be punctual and reliable, notifying the clinic of anticipated absences or changes in schedule
2. Abide by all state, federal, facility, and university rules and regulations
3. Inform the clinic and the CLPH field experience coordinator of any problems, concerns, or accidents/injuries.
4. Perform required duties in a timely and satisfactory manner.
5. Fulfill obligations of the Learning Agreement
6. Complete the required Sexual Harassment Training (p1 – Learning Agreement), and obtain liability insurance
Responsibilities of the University Program
1. Encourage the student’s productive contribution to the clinic.
2. Ensure the student’s academic eligibility to participate in the Field Experience.
3. Establish guidelines and standards for the Field Experience
4. Assign a faculty Field Experience Coordinator to serve as the academic advisor, to assist in establishing appropriate
objectives, liaise with the clinic, monitor the progress of the student, and evaluate the academic requirements
5. Maintain appropriate communication with the clinic and clarify any University policies and procedures.
Responsibilities of the Field Experience Site (Clinic)
1. Encourage and support the learning aspect of the student’s program.
2. Designate a professional staff person/employee to serve as an advisor/supervisor with responsibilities to help the
student understand the clinic and its culture, to assist in the development of learning objectives, to confer regularly
with the student regarding progress, and to evaluate student progress.
3. Provide appropriate supervision for the student and assign duties that are related to the student’s educational benefit.
4. Provide a safe environment for the student to experience typical professional duties, and make available appropriate
equipment and supplies.
5. Agree not to displace regular workers with student’s functions.
6. Notify the CLPH Field Experience Coordinator immediately upon any significant changes in the student’s work status,
schedule, or performance.
7. Enable the CLPH Field Experience Coordinator to conduct pre-arranged phone conferences and/or site visits to confer
with the student and clinic preceptor.
8. Complete and return mid-term and final evaluations of the student’s performance. These will be emailed directly.
9. Maintain all liability and other coverage as required by law and comply with Fair Labor Standards Act guidelines when
providing unpaid internships in the “for-profit” sector.
10. Not discriminate on the basis of race, color, creed, religion, national origin, sex, sexual orientation, age, marital status,
disability or status as a disabled veteran or Vietnam era veteran.
11. Regardless of direct or indirect services to clients, should the placement site have clients of vulnerable population
pursuant to RCW 43.43.830-.845, Placement site agrees to obtain written permission from the student to perform the
required criminal background check. Should negative information appear on the criminal report, placement site will be
responsible for determining if the field experience will be allowed.
Insurance Coverage
Central Washington University does not have an obligation nor does it provide health, accident, or hospitalization
insurance. Washington State laws do not allow the University to extend any of its professional or general liability coverage
to students to cover their personal actions or negligence while performing work or volunteering at any program site. If the
use of a personal vehicle is required by the student for the benefit of the field site, Central Washington University
provides no insurance for the student to operate this vehicle. Central Washington University has no liability for injury or
property damage that may result from personal vehicle use. The CLPH Field Experience program is for the intern’s
academic development for which they receive academic credits. Students are not be entitled to any Labor and Industries
or Unemployment Compensation benefits during or after the completion of the CLPH Field Experience Program.
Hold Harmless Clause
The Program Site and use of any and all of its facilities shall be undertaken by the Student at their own sole risk, and
that Central Washington University shall not be liable for any claims, demands, injuries, damages, actions, or causes of
actions, whatsoever by the Student or property arising out of or connected with the Program or with the use of any and
all services, or facilities associated with the Program site, whether or not sponsored by Central Washington University.
Each party shall defend, indemnify and hold the other party, its officers, officials, employees and volunteers harmless
from any and all claims, injuries, damages, losses or suits including attorney fees, arising out of injuries and damages
caused by each party’s own negligence.
SIGNATURE BLOCK
We, the undersigned, agree with the validity of the Learning Agreement as proposed. The Employer and the University
agree to provide the necessary advising, direction and supervision to ensure that the maximum educational benefit is
achieved from the Student's field experience. The Student agrees to abide by the guidelines as outlined in the Student
Workbook. The Employer Supervisor will evaluate the accomplishment of the Student's Learning Plan and work
performance at the end of the grading period. The Faculty Advisor will evaluate the field experience and will award
credit for successful accomplishment of the academic requirements and the Learning Plan.
Student:
Date
Employer Supervisor:
Date
CLPH Field Experience Coordinator:
Date
CLPH Program Director:
Date
IF NECESSARY: International Student Advisor or Study Abroad Exchange:
_____________________
Clinical Physiology Field Experience Student Release Form
Date
I, PETA J SMITH,
ID #:
00022210
am a student at Central Washington University, and plan to
undertake my Clinical Physiology Field Experience during:
Fall
_2016_
Winter _____
at the following location: OrthoPT
Spring _____
Bigville,
WA
Summer
_____
99991
Central Washington University itself does not control the way in which learning sites are structured or operate. In
granting credit for this Field Experience, the University affirms that, to the best of its knowledge, the experience is an
appropriate curricular entity and worthy of university credit; however, it makes no other assurances, expressed or
implied, about any travel and living arrangements the student has made.
Central Washington University does not knowingly approve program opportunities that pose undue risks to their
participants. However, any program or travel carries with it potential hazards which are beyond the control of the
University, its Board of Trustees, officers, agents or employees.
INSURANCE COVERAGE
I understand that some Field Experience sites may require that I have sufficient health, accident, and hospitalization
insurance to cover me during my Program. I further understand that I am responsible for the costs of such insurance and
for any expenses not covered by this insurance, and I recognize that Central Washington University does not have an
obligation nor do they provide me with such insurance. I also understand that Central Washington University
recommends that I have sufficient health, accident, and hospitalization insurance during my Field Experience.
I assume full responsibility for any undisclosed physical or emotional problems that might impair my ability to complete
the experience, and I release Central Washington University from any liability for injury to myself or damage to or loss of
my possessions.
I understand that Washington State Laws do not allow the University to extend any of it professional or general liability
coverage to students, to cover their personal actions or negligence while performing work or volunteering at any Program
site. Therefore I accept full legal and financial responsibility for my actions while performing my Program responsibilities,
and understand that I am personally liable for any injury or damage that I may cause.
I understand that if I use my personal vehicle for the benefit of the organization with whom I perform my Program,
Central Washington University provides no insurance for me to operate a personal vehicle and also has no liability for
injury or property damage which may result from that use. I agree to rely solely on my personal vehicle insurance
coverage and on any insurance coverage provided by the Program site.
I understand that because my Program is for personal gain and academic credits, I will not be entitled to any labor and
industries or unemployment compensation benefits during or after the completion of my Program from the University.
Further, I understand that Central Washington University assumes no liability for injury that I may suffer in the course of
my Program, and requires that I be responsible for ascertaining whether my Program site provides Workers
Compensation coverage for me.
PERSONAL CONDUCT
I understand that the responsibilities and circumstances of this off-campus Field Experience Program may require a
standard of professional etiquette that may differ from that of Central Washington University. Therefore, I indicate my
willingness to understand and conform to the professional standards of the Program site. In addition, I am in full
understanding that the designated Program site has requirements that I must meet prior to starting at the Program site,
and failure to provide such documentation may result in immediate cancellation of my Field Experience. I agree to
provide all site-required documentation to the CLPH Field Experience Coordinator prior to starting. An email from a
person in authority at the Field Experience site indicating that all requirements of the site have been met may be
submitted in lieu of these documents. I also further understand that it is important to the success of the present Program,
and the continuance of future Programs, that interns observe standards of conduct that would not compromise Central
Washington University in the eyes of individuals and organizations with which it has dealings. I acknowledge the
responsibility of Central Washington University through the Clinical Physiology Field Coordinator, to set rules and
interpret conduct for this purpose. I agree that should Central Washington University and its Clinical Physiology Field
Coordinator decide that I must be terminated from my Field Experience because of conduct that might bring the CLPH
Program into disrepute or the Field Experience site into jeopardy, that decision will be final and may result in the loss of
academic credit.
GENERAL RELEASE
I hereby authorize Central Washington University to release a copy of my criminal history background check, excluded
party checks, proof of immunizations, CPR Certification Card, student transcript, and/or any other documents so required
by the Field Experience site in consideration of my placement in their facility. I understand that any negative information
found on any materials required by the Field Experience site prior to placement may affect my consideration for
placement at this site. Therefore, I agree to release the University, its officers, agents and employees from any liability
associated with my site placement should any negative information by found and my placement denied. I understand that
Central Washington University reserves the right to make cancellations, changes or substitutions in cases of emergency or
changed conditions or in the general interest of the academic program. It is further expressly agreed that the Field
Experience site and use of any and all of its facilities shall be undertaken by me at my own sole risk, and that Central
Washington University shall not be liable for any and all claims, demands, injuries, damages, actions, or causes of actions,
whatsoever to me, by me, or property arising out of or connected with the Program and with the use of any and all
services, or facilities associated with the Program, whether or not sponsored by Central Washington University. I do
hereby release, discharge and covenant not to sue Central Washington University, its Board of Directors, officers, agents
or employees regarding any and all liability that may arise out of injury, harm, death, or property damage, resulting from
my participation in this Field Experience Program.
Student Signature: ________________________________________ Date: _________________________________
Date of Birth: ________________________________________
(Revised: Fall Qtr 2016)
STUDENT GENERAL LIABILITY AND MEDICAL MALPRACTICE INSURANCE PROGRAM
Description: If elected, the Student General Liability and Student Medical Malpractice Insurance Programs insures
the general and professional liability of enrolled CWU students who furnish mental and physical health-related
professional services required under curriculum or internships. Examples include athletic trainer, mental health
counselor, school counselor, dance therapist, drug and alcohol counselor, marriage and family counselors, audiologist,
language-speech pathologist, dietitian, physical therapist, social worker, occupational therapist, and services in the
physical education, health and recreation fields. Any academic department within these and similar fields should make
the General Liability and Student Medical Malpractice Insurance available to their enrolled students for purchase. The
limit of liability under the policy is $1,000,000 per occurrence with a $3,000,000 per school annual aggregate.
Coverage is limited to the insurance policy terms, conditions and exclusions.
Cost & Effective Date: The cost is $20.00 for coverage through the duration of the annual master policy period,
beginning and ending on September 1st of each year. It is the student's responsibility to make sure their premium is
paid and their coverage is current. Download the form at http://www.cwu.edu/business-services/insurance-forms-andlinks
Certificate: The student will receive a current certificate of insurance from the Business Services Office the
enrollment form and proof of payment are received. A certificate of insurance may be required by the clinical
organization at which you will be an intern.
Claims: Potential and actual claims must be reported immediately to Business Services by the student and the
University department overseeing the clinical placement. Business Services will notify the Office of Financial
Management and the carrier of the potential or actual claim.
Important Note: Coverage is only available to Central Washington University Students. This summary is designed to
give you a general overview of the insurance coverage. It should not be construed as a representation or legal
interpretation of coverage. Contact Business Services for specific information about the program and coverage terms,
conditions and exclusions.
Business Services
400 East University Way • Ellensburg, WA 98926-7474 • Office: 509-963-2310 •
Kamola Hall, Room 128 • Web: www.cwu.edu/business-services
EEO/AA/TITLE IX INSTITUTION
•
FOR ACCOMMODATION E-MAIL: CDS@CWU.EDU
Fax: 509-963-2336
STUDENT GENERAL LIABILITY AND MEDICAL MALPRACTICE INSURANCE
ENROLLMENT FORM
Cost: $20.00
Name of Student & ID#
Student Email Address
Permanent Mailing
Address
City, State & Zip
Student Phone Number
CWU Program Name
Activity & Dates
Activity: Internship
Start Date:
E nd Date:
Name of CWU Adviser
Name & Location of
Internship Site
This coverage provides general and professional liability with limits of $1,000,000 per occurrence with a $3,000,000
annual aggregate limit per school. Coverage is limited to the insurance policy terms, conditions and exclusions.
Coverage is only available to enrolled Central Washington University Students. This summary is designed to give you
a general overview of the insurance coverage. It should not be construed as a representation or legal interpretation of
coverage. Contact Business Services for specific information about the program and coverage terms, conditions and
exclusions.
Enrollment & Payment Instructions:
In-person enrollment: Take this form and $20.00 to the Cashier’s Office in the basement of Barge Hall, they will
send it to Business Services, or you can deliver the completed form and copy of your receipt to Business Services at
Kamola Hall Room 128 (West Entrance) for processing. Your certificate of insurance will be emailed to you at the
email address provided on this form.
On-line enrollment: Email medmal@cwu.edu or fax (509) 963-2336 the completed form to Business Services for
processing. Once you have sent the enrollment form, please contact Student Financial Services/Student Accounts at
(509) 963-3546 to pay the $20.00 fee over the phone. Once payment is processed, please ask the cashier to forward a
copy of the receipt to MS-7474. Your certificate of insurance will be emailed to you at the email address provided on
this form once the proof of payment is received.
Business Services
400 East University Way • Ellensburg, WA 98926-7474 • Office: 509-963-2310 •
Kamola Hall, Room 128 • Web: www.cwu.edu/business-services
EEO/AA/TITLE IX INSTITUTION
•
FOR ACCOMMODATION E-MAIL: CDS@CWU.EDU
Fax: 509-963-2336