Are you involved in modifications of the curriculum? ☐Yes ☐No Have you been evaluated by your supervisor? ☐Yes ☐No Date of most recent evaluation? Are there systems in place to demonstrate the ☐Yes ☐No effectiveness of the program? Are adequate controls to assure quality of ☐Yes ☐No delegated responsibilities Are you responsible for: Administration of the educational program? ☐Yes ☐No If response is “no” Organization of the educational program? ☐Yes ☐No to any of these 7 Supervision of the educational program? ☐Yes ☐No questions, Continuous quality review and improvement of the describe below* ☐Yes ☐No educational program? who is responsible Long range planning and on-going development of the and how that ☐Yes ☐No program? responsibility is Effectiveness of the program? ☐Yes ☐No attained. Cooperative involvement of the medical director? ☐Yes ☐No * Who is responsible and how is that responsibility attained? Insert job description of the Program Director… here APPENDIX C3 Curriculum – Paid Faculty or Instructional Staff Information Name: ☐ Paid Faculty ☐ Instructional Staff, Specify: How long have you been serving in the present position with the program? Are you currently certified as a AT Professional? ☐Yes ☐No
Are you involved in modifications of the curriculum? ☐Yes ☐No Have you been evaluated by your supervisor? Date of most recent evaluation? ☐Yes ☐No Are there systems in place to demonstrate the effectiveness of the program? ☐Yes ☐No Are adequate controls to assure quality of delegated responsibilities ☐Yes ☐No Are you responsible for: Administration of the educational program? ☐Yes ☐No If response is “no” to any of these 7 questions, describe below* who is responsible and how that responsibility is attained. Organization of the educational program? ☐Yes ☐No Supervision of the educational program? ☐Yes ☐No Continuous quality review and improvement of the educational program? ☐Yes ☐No Long range planning and on-going development of the program? ☐Yes ☐No Effectiveness of the program? ☐Yes ☐No Cooperative involvement of the medical director? ☐Yes ☐No * Who is responsible and how is that responsibility attained? Insert job description of the Program Director… here APPENDIX C3 – Curriculum Paid Faculty or Instructional Staff Information Name: ☐ Paid Faculty ☐ Instructional Staff, Specify: How long have you been serving in the present position with the program? Are you currently certified as a AT Professional? ☐Yes ☐No
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