Community-Based Clinical Education (CBCE) Program

Community-Based Clinical Education (CBCE) is a distributed model of teaching and learning where students gain real-world, diverse, and rigorous clinical experiences. With a distributed network, students can engage in clinical immersions in many different health systems and geographic regions.

CBCE is an umbrella term, encompassing community-based internships (CBI), preceptorships, clerkships (e.g., within the Veteran’s Administration, or VA), and all other forms of external practice-based learning available to qualified senior chiropractic interns.

The Doctor of Chiropractic Program (DCP) is a twelve (12) academic quarter program. Starting in quarter 10, qualified senior chiropractic interns can begin their community-based placement. Prior to this experience, senior interns have completed at least two academic quarters in DCP-managed sites.

Learn more by reading the Community-Based Clinical Education Manual

Community-Based Clinical Educator Application

APPLICANT INFORMATION

Name

First Last

Today's Date

Office Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone

Office Fax

Email Address(Required)

Website

Satellite Office Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Satellite Office Phone

Satellite Office Fax

Satellite Office Email Address

Satellite Office Website

How do you prefer to be contacted?

Select one.

Phone

Microsoft Teams

What is a good day of the week and time to reach you?

Malpractice Insurance Carrier

Expiration Date

DC License Number

Date Initially Issued

Expiration Date

Have you ever had your license suspended or revoked in your current or any other jurisdiction?

Yes

If yes, please provide details.

Are you currently facing, or have you ever been subject to action by a jurisdictional licensing board?

Yes

If yes, please provide details.

Have you ever been convicted of a felony?

Yes

Have you ever had any formal disciplinary action and/ or been a party to a malpractice settlement or judgment?

Yes

If yes, please provide details.

APPLICANT EDUCATION

Chiropractic College/Alma Mater

First Year of Licensure

Other Professional Licensure

Post-Graduate Residencies

Specialty Board Certifications

Do you have current professional CPR/AED/First Aid certification?

Yes

OFFICE INFORMATION

Average Number of Patient Visits per Week

Average Number of New Patients per Week

HIPAA compliant?

Yes

Notice of privacy practice displayed?

Yes

Electronic Health Records

Yes

Software Name

Professional Licensed Staff

Please list first and last name and credentials

What are your regular patient clinic hours?

Please list the times and days of the week. Include lunch breaks.

DOCTOR PROFILE

In an effort to identify unique aspects of your practice, we ask that you complete the following profile which will help our interns to know more information about your practice.

Clinic Name

Location(s) (City/Clinic)

Provide a brief description of your practice including your general approach to patient care and techniques used.

Please note, this description will be provided to students as they enter the matching process.

Are you interested in also being a sports medicine practicum site?

Yes

Student Engagement in Clinical Activities

In order to establish and maintain clear expectations for each student’s practicum activities the following are the minimum expectations of what a prospective practicum clinician/site should offer the student:

Evaluation and assessment of active people and/or athletic patients
Treatment or management of injured or ill active people and/or athletic patients, including but not limited to rehabilitation/active care, assignment of exercise or activity including modifications, and recommendations for safe and healthy return to activity post injury/illness, or aid in athletic performance.
Provision of tape, bracing, padding, or other supportive means to aid in safe return to health, or aid in athletic performance.
Communication opportunities with patients, stakeholders, and other health care professionals as appropriate.

Other areas that a student may be involved in are acute care of urgent, emergent, or first aid situations. The program recognizes not all Clinical Practicum Supervisors engage with these situations outside of what may occur in normal clinic operations.

As a prospective Clinical Practicum Supervisor, I agree that my clinic/office or other activities can meet the learning needs outlined above.

During practicum, I anticipate that the student will have the opportunity to observe:

New patient histories

New patient examinations

Diagnosis/management plan

Patient re-evaluation

Joint mobilization and/or manipulation

Soft tissue treatment

Active care/rehabilitation

Patient education

During practicum, I anticipate that the student will have the opportunity to directly participate in:

New patient histories

New patient examinations

Diagnosis/management plan

Patient re-evaluation

Joint mobilization and/or manipulation

Soft tissue treatment

Active care/rehabilitation

Patient education

Is there anything else you anticipate the student will have the opportunity to observe or participate in at your clinic?

Athletic Teams or Team Affiliations:

Please note that all affiliations are subject to review and approval by the sports medicine program.

Team Name

Sport

Level (youth, high school, etc)

Additional outside events or entities that you are affiliated with that may provide clinical experience for the student.

Please note that all affiliations are subject to review and approval by the sports medicine program.

Languages spoken in practice:

What are your practice demographics (age, diversity)?

Do you have a current UWS student that is interested in participating in the CBCE program at your office?

Yes

What is the name of that student?

How did you hear about CBCE program?

UWS student

Word of mouth

UWS alumni listserv

Printed flyer

UWS website

UWS switchboard

Other

If other, please explain.

File Upload

All items and documents listed below must be submitted with this CBCE application.

Resume (CV)

Max. file size: 20 MB.

Copy of current chiropractic license

Max. file size: 20 MB.

Copy of current declaration of malpractice insurance

Max. file size: 20 MB.

Copy of current x-ray supervisor and operator license (if applicable)

Max. file size: 20 MB.

Claims history authorization

Download and complete the claims history authorization form.

Max. file size: 20 MB.

ACKNOWLEDGEMENT

By checking the following, you agree that the statements herein below are true and accurate.

As a Community-Based Clinical Educator, I agree to comply with all jurisdictional regulations regarding chiropractic internship, preceptorship, or clerkship.

I affirm that my chiropractic license is current and in good professional standing.

I authorize UWS to access CIN-BAD/national practitioner and state or provincial data bases to verify my status to practice.

I understand and agree that student interns may not represent themselves or be referred to as a "doctor" or as a licensed professional.

I understand that acceptance into the CBCE program is contingent on application review, and if accepted, I will be provided with a participation agreement stipulating the terms of appointment.

If you have any further comments you would like to share, please add them here.

If you have any questions regarding the application or requested documents, please call Patrick Battaglia at 636-222-4392.

E-Signature

First Last

Date