Sensory aids Recreation Environmental modification Accessible transportation Orthotics / prosthetics / bracing Other Specify APPENDIX F4 Field Internship Institutional Data Form – Accreditation Self Study Report AFFILIATE #: [ ] INTERNSHIP AFFILIATION MATRIX Name: Address: Chief Administrative Officer: Telephone #: Distance from location of program? [ ] [ ] [ ] Is there a signed, current agreement with this affiliate? Yes No [ ] [ ] Who supervises the students? field agency personnel program personnel [ ] [ ] Are the preceptors formally trained? Yes No For how many hours? [ ] [ ] Is there a quality improvement program that reviews runs? Yes No Assistive Technology Areas # observations Seating and mobility AAC (Augmentative/alternative communication) Cognitive and Executive Function Aids Education/learning/accessible instructional materials
Sensory aids Recreation Environmental modification Accessible transportation Orthotics / prosthetics / bracing Other Specify APPENDIX F4 – Field Internship Institutional Data Form Accreditation Self Study Report AFFILIATE #: [ ] INTERNSHIP AFFILIATION MATRIX Name: Address: Chief Administrative Officer: Telephone #: Distance from location of program? [ ] Is there a signed, current agreement with this affiliate? [ ] Yes [ ] No Who supervises the students? [ ] field agency personnel [ ] program personnel Are the preceptors formally trained? [ ] Yes [ ] No For how many hours? Is there a quality improvement program that reviews runs? [ ] Yes [ ] No Assistive Technology Areas # observations Seating and mobility AAC (Augmentative/alternative communication) Cognitive and Executive Function Aids Education/learning/accessible instructional materials
self-study.docx