Your Name (required)

Your Phone Number 
or E-mail (required)

School You Attend    

(NOTE:  Your name will not be released, but we may need to contact you for additional information)

Name of Nominee   
AND credentials

Facility of Nominee 

Facility Phone Number

Score each of the following behaviors as follows:
1 = Rarely   2 = Occasionally   3 = Usually    4 = Frequently   5 = Always

Criteria I:  Consistently promotes a positive atmosphere for effective verbal and nonverbal interaction
Score         
  Provides positive & negative feedback in a timely manner, in private if necessary.
  Is an active listener.
  Communicates openly and honestly in a non-threatening manner.
  Teaches in an interactive way; encourages dialogue.

Criteria II:  Strives to establish good rapport with student, respecting both their professional and personal concerns.
Score         
  Establishes an environment in which the student feels comfortable.
  Demonstrates positive regard for the student and provides appropriate support
          for student concerns, frustrations, and anxieties.
  Presents the student as a professional to others and offers professional support.
  Demonstrates a genuine concern for patients.
  Is empathic.

Criteria III:  Uses good judgement, maintains composure and exhibits qualities consistent with ethical standards of practice.
Score         
  Employs physical therapy with competence
  Serves as an appropriate role model - is an ethical, professional member of
          the health care team.
  Demonstrates leadership among peers and supportive personnel, students,
          and patients.
  Respects the rights of peers, supportive personnel, students and patients.
  Maintains composure
  Manages own time well - is flexible.
  Interested in furthering his / her professional skills.

Criteria IV:  Facilitates didactic and clinic experience to promote growth and professional independence.
Score         
  Is available to the student and/or schedules regular meetings.
  Assists the student in managing his/her time well
  Plans effective learning experiences and utilizes situations for learning as
          they arise.
  Allows the student appropriate, progressive independence.
  Evaluations are done in a timely, accurate and constructive way.
  Makes a relationship between academic knowledge and clinical practice.
  Recognizes own limitations and directs students to appropriate sources.
  Questions / coaches in a way to facilitate learning.
  Helps student define specific objectives for the clinical education experience.

COMMENTS: Consider innovative techniques used or other characteristics this person possesses that might be helpful in the selective process.