* A new clinical intent form must be filled out for each treatment or simulator rotation. Copy of this intent form will be reviewed with the staff, faxed to the Clinical Coordinator and posted on the treatment unit for the entire rotation. Any revisions to the original Clinical Intent will need to be faxed to the Clinical Coordinator.
This is to clarify what I need to accomplish during my ___ week rotation. I intend to complete the following competency evaluations. *
Schedule of mid and final evaluation due dates: Clinical Evaluation by Clinical Supervisor – Mid Eval (1/2 way through each tx unit rotation / Due: _________________________
Clinical Evaluation by Clinical Supervisor – Final Eval (end of each tx unit rotation / Due:__________________________
*Student is required to evaluate the clinical site & instructors by the end of the clinical rotation.
At any point in the rotation, the Program Director, Clinical Coordinator, clinical supervisors and the student may meet to review what progress has been made and what areas need to be improved.
Policy Infractions of the policies of the Radiation Therapy Program are determined by the clinical staff and/or the Clinical Coordinator. Designated clinical supervisors are expected to be forthcoming with any information regarding student clinical infractions. If the clinical supervisor prefers, the Clinical Coordinator will write up the clinical infraction and address the issue with the student.
Procedure 1. A Clinical Infraction form will be written up and reviewed with the student by the person issuing the written warning.
2. The policy(ies), incident(s), and consequences of the infraction will be noted on the document and the student will be asked to sign it along with the person issuing the clinical infraction.
3. A student signature indicates only that a warning has been received. If the student feels that extenuating circumstances should be considered in regard to the identified infraction(s), then the student should submit the information to the Clinical Coordinator & Program Director in writing.
4. The Clinical Infraction will need to be reported by the clinical supervisor to the Clinical Coordinator who will address this with the student.
5. Receiving three or more clinical infractions in a clinical internship will result in a drop of one letter grade for that clinical internship.
6. The 4th clinical infraction will result in an additional drop in one letter grade.
7. The 5th clinical infraction will result in an additional drop in one letter grade.
8. Multiple Clinical Infractions will lead to either clinical probation or the student failing that clinical rotation.
This form serves as documentation of a clinical incident involving a radiation therapy student in the clinical education site. Upon completion of this form the original is placed in student’s file at the clinical site and a copy is sent to the Radiation Therapy Program Director at MCPHS. Students must also follow the specific policies and procedures of the clinical site regarding incident reports.
Name of Student:______________________________________________________
Date and Time of Incident:______________________________________________