Clinical Perfromance Instrument, adapted. Drnach, Grubler, Haley, 2015

1. Wheeling JesuitUniversity
Department of Physical Therapy
Student Clinical/Professional Skill Performance Evaluation*
International Service Learning
Student Name:
Evaluator Name:
Location:
Dates of Service Learning Experience:
1. Safety - Practices in a safe manner that minimizes the risk to patient,
self, and others. (CPI #1)
RATING SCALE
Beginner Advanced Intermediate Advanced Entry Beyond
Performance Beginner Performance Intermediate Level Entry
Performance Performance Performance Level
Performance
Evaluator Comments:
2. Communication - Communicates in ways that are congruent with
situational needs. (CPI #4)
RATING SCALE
Beginner Advanced Intermediate Advanced Entry Beyond
Performance Beginner Performance Intermediate Level Entry
Performance Performance Performance Level
Performance
Evaluator Comments:

2. Student Performance Evaluation
Page 2
3. Cultural Competence - Adapts delivery of physical therapy services with
consideration for patients’ differences, values, preferences, and needs.
(CPI #5)
RATING SCALE
Beginner Advanced Intermediate Advanced Entry Beyond
Performance Beginner Performance Intermediate Level Entry
Performance Performance Performance Level
Performance
Evaluator Comments:
4. ______________________________________________________________
RATING SCALE
Beginner Advanced Intermediate Advanced Entry Beyond
Performance Beginner Performance Intermediate Level Entry
Performance Performance Performance Level
Performance
Evaluator Comments:
Final Comments:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________ ________________________________
Clinical Instructor Signature / Date Student Signature / Date

3. * Adapted from: American Physical TherapyAssociation. (2006) Physical
Therapist Clinical Performance Instrument for Students. American Physical
TherapyAssociation. Department of Physical TherapyEducation. Alexandria. VA