APPENDIX F2 Field Internship Institutional Data Form – Accreditation Self Study Report AFFILIATE #: [ ] FIELD INTERNSHIP AFFILIATION MATRIX Name: Address: Administrative Officer: Telephone #: Distance from location of program? [ ] miles [ ] [ ] 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 [ ] [ ] Is there a quality improvement program that reviews runs? Yes No Assistive Technology # observations Seating and mobility AAC (Augmentative/alternative communication) Cognitive and Executive Function Aids Education/learning/accessible instructional materials Computer and mobile device access ADL (e.g., EADL-Electronic aids to daily living, dressing, bathing, etc.) Sensory aids Recreation Environmental modification
APPENDIX F2 – Field Internship Institutional Data Form Accreditation Self Study Report AFFILIATE #: [ ] FIELD INTERNSHIP AFFILIATION MATRIX Name: Address: Administrative Officer: Telephone #: Distance from location of program? [ ] miles 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 Is there a quality improvement program that reviews runs? [ ] Yes [ ] No Assistive Technology # observations Seating and mobility AAC (Augmentative/alternative communication) Cognitive and Executive Function Aids Education/learning/accessible instructional materials Computer and mobile device access ADL (e.g., EADL-Electronic aids to daily living, dressing, bathing, etc.) Sensory aids Recreation Environmental modification
CoA-RATE-Self-Study-Report-Format-Dec-2017_1.docx