Community Based Internship (CBI) Application - University of Western States

Your participation in the University of Western States Community Based Internship (CBI) program is greatly appreciated. This program is designed to further enhance the learning and skillset of our chiropractic interns in a practice setting outside the campus setting. The UWS doctoral program in chiropractic is a 12-quarter program. Interns may participate in the UWS CBI program during their 10th and 11th quarters. In their final 12th quarter, the intern may experience study in their preceptor clinical rotation.

Participation in this program is a privilege for interns. The participating interns have demonstrated the necessary competencies to help you with patient care. In addition to meeting competency, each intern provides a resume in support of their interest in the CBI program.

CBI interns are required to complete 25 weekly contact hours in patient care. By agreeing to participate in this program, you are also agreeing to provide 25 hours per week of patient care for the UWS intern.

In Oregon, applicants must be licensed for a minimum of four (4) years to participate in in the UWS CBI program. Washington state requires licensure for a minimum of five (5) years.

Please carefully review the required information on the CBI application. All items and documents must be submitted with the CBI application below.

Copy of current chiropractic license
Current curriculum vitae
Copy of current declaration of malpractice insurance
Claims history authorization
Copy of current x-ray supervisor and operator license (if applicable)

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

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 state?

Yes

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

Yes

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

APPLICANT EDUCATION

Chiropractic College/Alma Mater

Graduation Year

Other Degree(s) and College(s)

Post-Graduate Residencies

Chiropractic or Other Specialty Certifications

Did you participate in a CBI/preceptorship as a chiropractic student?

Yes

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

Yes

PRACTICE INFORMATION

Average Number of Patient Visits per Week

Average Number of New Patients per Week

Indicate the following techniques used in your office:

Please check box for each technique used.

Other selected – please describe:

Indicate the following adjunctive care used in your office:

Check all that apply.

LASER selected – please list type(s):

Other selected – please describe:

Do you routinely check for vital signs? (We strongly encourage our interns to routinely check vitals.)

Yes

Identify three outcomes a UWS student would experience in your practice:

Are you providing care to patients outside of your regular clinic hours? If so, please explain.

HIPAA compliant?

Yes

Notice of privacy practice displayed?

Yes

OFFICE INFORMATION

Electronic Health Records

Yes

Software Name

Professional Licensed Staff

Please list first and last name and credentials

Ancillary/Support Staff (Front Office)

Yes

Number of Staff Members

Ancillary/Support Staff (Back Office)

Yes

Number of Staff Members

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)

Primary techniques utilized:

Provide a brief description of your practice:

Languages spoken in practice:

What are your practice demographics (age, diversity)?

What is expected of an intern?

What duties will an intern perform in your clinic?

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

Yes

What is the name of that student?

How did you hear about CBI?

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 CBI 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 Internship (CBI) clinician, I understand and comply with all applicable rules and I will directly supervise the intern by being present within the clinic when the intern is participating in patient care.

I certify that I do not use “Pre-Paid Fee for Service Agreements”.

I agree to comply with all relevant laws regarding the practice of chiropractic. I understand that all patients are provided a health history, are appropriately examined, receive a diagnosis, and are provided a Review of Findings (ROF) and Informed Consent (IC).

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

I agree to notify UWS in writing within five (5) business days after being notified that a complaint has been filed with the licensing body. Failure to do so will result in immediate termination from the CBI program.

I understand that CBI interns may not represent themselves or be referred to as a doctor.

I have reviewed and agree to all terms and guidelines outlined therein the UWS Doctor of CBI Program Manual.

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 the CBI administrator at 503-251-5720 or assistant dean at 503-847-2565.

E-Signature

First Last

Date