REQUIREMENTS (BPSS-31, updated)
An affiliation agreement must be submitted and approved for each internship.
The following information/conditions must be included in the agreement. You can choose to use the sample agreement below.
A separate agreement exists for Nurse Aides.
1. Specific name and location of the proprietary school
2. Specific name and location of the internship site AND a photocopy
of its license
3. Exact dates/or length, of the affiliation experience
4. Number of students to be supervised during one affiliation period
5. Who is responsible for taking attendance at the affiliation site
will not displace or replace regular employees
agrees to maintain sufficient affiliation sites to accommodate all qualified students in the class
8. For medical
internships, incl. dental, school is responsible for insuring that student had a physical exam within 6 months before starting
the internship, and all inoculations recommended in the profession
9. School or Externship site (usually the school) is responsible for
insuring the student against injuries resulting from the internship. [The school either buys an insurance for interns and
rolls that insurance into the tuition, or makes available to interns the purchase of such insurance coverage. In the latter
case, the name of the company, the cost to students, and the extent of coverage, must be noted in the Externship Agreement].
10. Students and instructors
will be covered by liability insurance against liability towards third parties arising from the externship. The insurance
carrier, cost and exact insurance coverage must be identified.
11. The school
is responsible for providing all theory/practice instruction
site will use the performance evaluation tool provided by the school
will be supervised at ALL times during affiliation
14. How often the program coordinator will visit the affiliation
is responsible for the conduct of the students at the affiliation site
16. Specific conditions and procedures for terminating a student
17. How much notice must be given by either party to terminate the agreement
Sample Affiliation Agreement
Name of School: _____________________________________________
Address of School: _____________________________________________
AGREEMENT OF AFFILIATION WITH
Name of Facility: _______________________________________________
Address of Facility:
(name of school) has been approved to conduct a (name of program) training program which requires clinical experience
in a nursing facility. The (name of facility) has agreed to provide this supervised clinical experience. Therefore
the internship facility, now referred to as the affiliating institution, and the school, enter into the following agreement:
school will arrange for a maximum of ___ students to affiliate at (name of affiliating institution) for a period of ___ hours/days.
The specific hours/days will be agreed upon by a designee of each party and each will keep a copy of the schedule. There will
be no more than 10 students assigned to one clinical instructor. Taking attendance at the externship site will be the responsibility
of the school. Students will not displace or replace regular employees at the affiliating facility. The school agrees to maintain
sufficient affiliation sites to accommodate all qualified students.
medical internships only): Before the student begins the supervised clinical experience, he or she will show evidence of physical
requirements deemed necessary by agreement of both parties. The school is responsible for insuring that the student has had
a physical exam within six months, and all recommended inoculations, before the start of
(School/Affiliating Institution) is responsible
for student injury acquired at the affiliation site. Students and instructors will
also carry liability insurance and a signed statement indicating that they have a policy covering liability against third
parties resulting from this internship.
will be under the supervision of the clinical instructor(s) employed by the school, but may also be supervised by the professional
staff of the affiliating institution. The school is responsible for providing all theory/practice instruction. Students will
have received the necessary classroom and clinical instruction from the school before being authorized to perform patient
care. The clinical instructor(s) will make assignments and, with the help of the professional staff of the institution, will
evaluate each student’s performance using the evaluation instruments provided by the school.
clinical instructor will be present at all times students are present. The school’s program coordinator will make (frequency)
visits at the externship site.
school is responsible for the conduct/dress requirements of the students at the affiliation site. A student who does not satisfactorily
meet the requirements of this externship may be terminated. Prior to termination, the student will be notified of these deficiencies
and will be given (x) days to correct these deficiencies.
school recognizes that the affiliating institution has a service responsibility to its clients. If a student jeopardizes this
responsibility in any way, the affiliating institution has the right to demand that the student be removed from the clinical
agreement will begin on (month/day/year) and will be reviewed annually by both parties before the agreement is renewed. A
(Length of time) notice will be given by either party if the agreement will not be renewed. Both parties agree to contact
the Bureau of Proprietary School Supervision immediately upon requesting termination of the contract.
affiliating institution and the school will not discriminate in any way in regard to student learners, according to state
and federal laws.
School Representative, Name/Title