{"id":29419,"date":"2026-02-06T13:26:49","date_gmt":"2026-02-06T19:26:49","guid":{"rendered":"https:\/\/sites.austincc.edu\/health\/?page_id=29419"},"modified":"2026-02-06T15:24:29","modified_gmt":"2026-02-06T21:24:29","slug":"affiliation-agreement-request-form-out-of-service-area","status":"publish","type":"page","link":"https:\/\/sites.austincc.edu\/health\/facstaff\/affiliation-agreement-request-form-out-of-service-area\/","title":{"rendered":"Affiliation Agreement Request Form &#8211; Out of Service Area"},"content":{"rendered":"[vc_row][vc_column][vc_column_text][\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column width=&#8221;1\/6&#8243;][\/vc_column][vc_column width=&#8221;2\/3&#8243; css=&#8221;.vc_custom_1770410228828{background-color: #ffffff !important;}&#8221;][vc_column_text]\n<h3 style=\"text-align: center\">Out of Service Area<\/h3>\n<h1 style=\"text-align: center\">Affiliation Agreement Request Form<\/h1>\n[\/vc_column_text][vc_empty_space height=&#8221;1.5rem&#8221;][vc_btn title=&#8221;Return to Service Area&#8221; style=&#8221;custom&#8221; custom_background=&#8221;#003366&#8243; custom_text=&#8221;#ffffff&#8221; size=&#8221;sm&#8221; link=&#8221;url:https%3A%2F%2Fsites.austincc.edu%2Fhealth%2Ffacstaff%2Faffiliation-agreement-request-service-area%2F|title:Affiliation%20Agreement%20Request%20Service%20Area||&#8221;][vc_empty_space height=&#8221;1.5rem&#8221;]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f29418-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"29418\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/health\/wp-json\/wp\/v2\/pages\/29419#wpcf7-f29418-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"29418\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f29418-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<h2>ACC Information\n<\/h2>\n<p><label> Instructor Requesting Affiliation:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"instructor-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"instructor-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Instructor Phone Number:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"instructor-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"instructor-phone\" \/><\/span> <\/label>\n<\/p>\n<p><label> Instructor Email Address:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"instructor-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"instructor-email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Program for Inclusion in Affiliation:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"program-affiliation\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"program-affiliation\" \/><\/span> <\/label>\n<\/p>\n<p><label> Start Date for Clinical Placement (MM\/DD\/YYYY):<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"start-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"start-date\" \/><\/span> <\/label>\n<\/p>\n<h2>Facility Physical Address\n<\/h2>\n<p><label> Facility Legal Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"facility-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"facility-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Street Address:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"physical-street\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"physical-street\" \/><\/span> <\/label>\n<\/p>\n<p><label> City:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"physical-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"physical-city\" \/><\/span> <\/label>\n<\/p>\n<p><label> State:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"physical-state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"physical-state\" \/><\/span> <\/label>\n<\/p>\n<p><label> Zip Code:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"physical-zip\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"physical-zip\" \/><\/span> <\/label>\n<\/p>\n<h2>Facility Mailing Address\n<\/h2>\n<p><label> Street Address:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-street\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mailing-street\" \/><\/span> <\/label>\n<\/p>\n<p><label> City:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mailing-city\" \/><\/span> <\/label>\n<\/p>\n<p><label> State:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mailing-state\" \/><\/span> <\/label>\n<\/p>\n<p><label> Zip Code:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-zip\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mailing-zip\" \/><\/span> <\/label>\n<\/p>\n<h2> Facility Contact Information\n<\/h2>\n<p><label> Phone Number:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"facility-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"facility-phone\" \/><\/span> <\/label>\n<\/p>\n<p><label> Fax Number:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"facility-fax\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"facility-fax\" \/><\/span> <\/label>\n<\/p>\n<p><label> Name of Legal Signator:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"signator-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"signator-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Title of Legal Signator:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"signator-title\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"signator-title\" \/><\/span> <\/label>\n<\/p>\n<p><label> Signator's Email Address:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"signator-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"signator-email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Facility Department Level Contact Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"department-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"department-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Facility Department Level Contact Title:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"department-title\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"department-title\" \/><\/span> <\/label>\n<\/p>\n<p><label> Contact's Phone Number:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"department-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"department-phone\" \/><\/span> <\/label>\n<\/p>\n<p><label> Contact's Email Address:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"department-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"department-email\" \/><\/span> <\/label>\n<\/p>\n<p><label>Will the facility be using an affiliation agreement different from ACC's agreement?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-878\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-878\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-878\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<h2> Out of Service Area Affiliation Data\n<\/h2>\n<p><label>What is the rationale for requesting an outside of the ACC service area affiliation?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"oos-1\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"oos-1\"><\/textarea><\/span><\/label><br \/>\n<label>Does your program have the capability to meet student learning needs with existing in-service area clinical placements?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"oos-2\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"oos-2\"><\/textarea><\/span><\/label><br \/>\n<label>What is the specific department plan to supervise a student who is placed out of the service area?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"oos-3\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"oos-3\"><\/textarea><\/span><\/label><br \/>\n<label>How many times in the semester will faculty be doing on-site visits to monitor the student\u2019s learning, progress and to address any areas of concerns?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"oos-4\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"oos-4\"><\/textarea><\/span><\/label><br \/>\n<label>Does your department have sufficient travel funds budgeted to make on-site visits?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"oos-5\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"oos-5\"><\/textarea><\/span><\/label><br \/>\n<label>Have you made a preliminary visit to the out of service facility to assess the appropriateness of the site for student learning?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"oos-6\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"oos-6\"><\/textarea><\/span><\/label><br \/>\n<label>Have you discussed the feasibility of placing a student with the facility supervisor or department head?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"oos-7\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"oos-7\"><\/textarea><\/span><\/label><br \/>\n<label>Are educational institutions within this designated service area currently using this placement for their students?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"oos-8\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"oos-8\"><\/textarea><\/span><\/label><br \/>\n<div class=\"wpcf7-turnstile cf-turnstile\" data-sitekey=\"0x4AAAAAACSJvxbvP71iCaCt\" data-response-field-name=\"_wpcf7_turnstile_response\"><\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n<\/p><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][vc_column width=&#8221;1\/6&#8243;][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]<!-- \/wp:post-content -->[\/vc_column_text][\/vc_column][\/vc_row]","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column][vc_column_text][\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column width=&#8221;1\/6&#8243;][\/vc_column][vc_column width=&#8221;2\/3&#8243; css=&#8221;.vc_custom_1770410228828{background-color: #ffffff !important;}&#8221;][vc_column_text] Out of Service Area Affiliation Agreement Request Form [\/vc_column_text][vc_empty_space height=&#8221;1.5rem&#8221;][vc_btn title=&#8221;Return to Service Area&#8221; style=&#8221;custom&#8221; custom_background=&#8221;#003366&#8243; custom_text=&#8221;#ffffff&#8221; size=&#8221;sm&#8221; link=&#8221;url:https%3A%2F%2Fsites.austincc.edu%2Fhealth%2Ffacstaff%2Faffiliation-agreement-request-service-area%2F|title:Affiliation%20Agreement%20Request%20Service%20Area||&#8221;][vc_empty_space height=&#8221;1.5rem&#8221;][\/vc_column][vc_column width=&#8221;1\/6&#8243;][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text] [\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text][\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"author":4282,"featured_media":0,"parent":1297,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-29419","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/sites.austincc.edu\/health\/wp-json\/wp\/v2\/pages\/29419","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sites.austincc.edu\/health\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/sites.austincc.edu\/health\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/sites.austincc.edu\/health\/wp-json\/wp\/v2\/users\/4282"}],"replies":[{"embeddable":true,"href":"https:\/\/sites.austincc.edu\/health\/wp-json\/wp\/v2\/comments?post=29419"}],"version-history":[{"count":0,"href":"https:\/\/sites.austincc.edu\/health\/wp-json\/wp\/v2\/pages\/29419\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/sites.austincc.edu\/health\/wp-json\/wp\/v2\/pages\/1297"}],"wp:attachment":[{"href":"https:\/\/sites.austincc.edu\/health\/wp-json\/wp\/v2\/media?parent=29419"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}