AT Program Clinical Experience Hour Form
Athletic Training Clinical Experience Hour Form Name: ________________________________________ Clinical Level: ___________________________ Clinical Rotation: _______________________________ Preceptor: ______________________________ ATS: Be sure to indicate “Day Off”. Physician hours must be noted separately if part of Course Requirement. Daily Hours: Mon. Tues. Wed. Thurs. Fri. Sat. Sun. TOTAL Date Facility Sport Time In: Time Out: Daily Hours In Proper Dress Code: √=Yes Ø=No (If “no” see below*) Preceptor Initials: ATS should communicate all absences with their assigned Preceptor. I, the ATS, attest that all information on this “Clinical Experience Hour Form” is accurate. ATS Signature: _________________________________________ Date: ____________________ Preceptor Signature: ____________________________________ Date: ____________________ Incident/Violation Report: (Preceptor only) Insubordination Theft/Vandalism Conduct Unbecoming an AT Unprofessional Behavior Sexual Harassment Dress Code Violation Breach of Duty Falsifying Hours Chronic Tardiness Unexcused Absences Academic Dishonesty Drug/Alcohol Abuse Other ___________________________________________________ Please refer to “Disciplinary Incident Reporting Form” for further documentation when needed. REFER to the BACK of this form to document your educational experiences for the week. Cumberland University Athletic Training Student Experience Evaluation Athletic Training Handbook 38 Please check all that apply and describe where necessary: Cleaning/Set-up (coolers, ice, etc.) Practice Game _____________________ First Aid/Emergency Care: Wound Care Blister Care Steri-strips Activated EAP Crutch/Cane Fitting Spineboarding Splinting Other: ___________________________ Taping/Wrapping: Thumb Finger Hand Wrist Forearm Elbow Shoulder Ribs/Trunk Hip/Groin Thigh Knee Lower Leg Ankle Foot Toes Other: ___________________________________ Injury Eval (s): (Describe eval/re-eval, initial management, and any referral or attach copy of Injury Report) 1) 2) Rehab/Modalities (Describe details of Rx/Tx & Modalities, including copy of Progress Reports) 1) 2) Communicated with the Head Coach/Asst. Coach/Support Staff, etc regarding injuries Performed Administrative Duties Filing Computer Logs Eval Documentation Rehab Documentation Inventory Other: ____________________ Observed Physician’s Clinic (Describe what you learned): ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ATS Signature: _____________________________________ Date: _________________ Preceptor Reviewed: _________________________________ Date: _________________ AT Clinical Education Coordinator: _____________________________ Date: _________________