Community-Based Clerkship – Doctor Application

Application to the Community Based Clerkship

Thank you for your interest in our Community Based Clerkship (CBC) program. Clinicians like you invite students into their practices, providing expert guidance, instruction, and opportunity critical to learning the science, art, and philosophy of health care. We appreciate the significant commitment doctors make to the interns. We hope you will also derive many benefits from the CBC program and the relationships you will build.

We are excited to learn about your clinic and how your experience and knowledge will benefit our students. The steps outlined below and the information required is important to Clinical Education in determining fit for our CBC program. Submitting a complete application will move you through our credentialing program quickly.

Step1

Complete the “Doctor Profile”

Step 2

Choose three recent (within the last year) patient files to be sent. It is critical that identifying patient information is removed/redacted. The file will be rejected if any patient-identifying information is included. Print the “File Check List” to each patient file and attach it as a cover sheet to the patient file.

Step 3

Complete the “Teaching and Learning Questionnaire.” Your answers provide Clinical Education information to better understand your teaching philosophy and mentorship style. The questions also provide you with some insight into the responsibilities of a CBC Clinician.

Step 4

Please upload the following additional items:
– CV (resume)
– Copy of current Chiropractic license
– Evidence of malpractice insurance
– Copy of your current BLS certificate

"*" indicates required fields

Step 1 of 4

Doctor Profile

Doctor's Name*

First Last

Office Name*

Office Address*

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

Office Phone Number*

Office Email*

Chiropractic School you graduated from*

Graduation Date*

6. Do you accept Medicare? Medicaid? Personal Injury? Workers Compensation? Commercial Insurance (ie. BlueCross, United, Humana, etc.)?*

Yes

No

If yes, which ones?

Do you have a working x-ray machine?*

Yes

No

If yes, Digital or plain films?

Digital

Plain Films

Main Chiropractic techniques used in practice?*

How many patient visits do you see in a typical week?*

How many new patients do you see in a typical month?*

There is no requirement to pay the student intern or to offer any financial incentive to come to your office. However, we have been asked by some doctor’s if they are allowed to compensate the student intern. Therefore, will you be paying the student any wages or providing assistance for housing as a benefit (optional)?

Yes

No

Teaching and Learning Questionnaire

The College of Chiropractic program provides a professional education comprised of the knowledge, skills and attributes necessary for one to practice chiropractic effectively, ethically, and safely as a portal-of-entry, primary care chiropractic physician.

The following questions help Clinical Education better understand your unique clinic and how you and your staff will support our students learning needs.

As a chiropractor, describe how you recognize the need for (detect) and treat (correct) a chiropractic subluxation. Describe how your treatment fits into the preservation and restoration of health.*

Describe specific types of chiropractic adjustments utilized in your practice to facilitate neurological and biomechanical integrity.*

Please list and explain the adjunctive therapies used in your clinic to support patient care needs.*

Describe how you promote the concepts of health and wellness in your clinic.*

Describe how you and your clinic promote interdisciplinary care.*

Describe the use of outcome measure in your treatment plans.*

Describe what evidence informed practice means to you and how you support this model in your practice (diagnostic and treatment procedures, etc.).*

Describe what is most rewarding / fulfilling about providing chiropractic care.*

Describe the atmosphere/culture you and your staff promote in your clinic.*

Provide examples of how you will integrate an intern into your practice.*

Describe how you will provide close observation, mentorship, and respectful feedback to interns as they learn under your supervision.*

Strong business skills are a very important part of opening and running a practice. Describe how you and your staff will provide learning opportunities to gaining business skills and knowledge*

Provide a Teaching Philosophy Statement or Statement of Purpose.*

Once all information in Steps 1-4 has been received by Clinical Education department, you will receive notification whether your application has been accepted (fully accepted, or conditionally accepted with recommendations). Once accepted you will receive a packet containing the CBC handbook and other related information about the program. In the case your application has been conditionally accepted or denied you will receive notification and recommendations. You will also receive notification to schedule a credentialing visit performed by a Clinical Education representative. This visit (interview) will be done either remotely via Zoom / Teams or in person, depending on your clinic location.

Thank you,

Dr. Brian Wentz

Director of Clinical Education

bwwentz@campbellsville.edu