ACC Information

Instructor Requesting Affiliation:

Instructor Phone Number:

Instructor Email Address:

Program for Inclusion in Affiliation:

Start Date for Clinical Placement (MM/DD/YYYY):

Facility Physical Address

Facility Legal Name:

Street Address:

City:

State:

Zip Code:

Facility Mailing Address

Street Address:

City:

State:

Zip Code:

Facility Contact Information

Phone Number:

Fax Number:

Name of Legal Signator:

Title of Legal Signator:

Signator's Email Address:

Facility Department Level Contact Name:

Facility Department Level Contact Title:

Contact's Phone Number:

Contact's Email Address:

Will the facility be using an affiliation agreement different from ACC's agreement?
YesNo

Out of Service Area Affiliation Data

What is the rationale for requesting an outside of the ACC service area affiliation?

Does your program have the capability to meet student learning needs with existing in-service area clinical placements?

What is the specific department plan to supervise a student who is placed out of the service area?

How many times in the semester will faculty be doing on-site visits to monitor the student’s learning, progress and to address any areas of concerns?

Does your department have sufficient travel funds budgeted to make on-site visits?

Have you made a preliminary visit to the out of service facility to assess the appropriateness of the site for student learning?

Have you discussed the feasibility of placing a student with the facility supervisor or department head?

Are educational institutions within this designated service area currently using this placement for their students?