Affiliation Agreement Requirements

BPSS-PG 39, updated 05/2018

A signed affiliation agreement must be submitted for each internship site. The following information/conditions must be included in the agreement. You can choose to use the sample agreement below. Do not use this agreement for Nurse Aides, Home Health Aides and Ultrasound. A separate standard agreement exists for those fields.

  1. Specific name and location of the proprietary school.
  2. Specific name and location of the internship site AND a photocopy of its license, if the business requires a license.
  3. Exact dates/or length, of the affiliation experience, hours per day/week and total.
  4. Number of students to be supervised during one affiliation period.
  5. Process for verification for attendance at the affiliation site.
  6. Assurance that students will not displace or replace regular employees.
  7. The school agrees to maintain sufficient affiliation sites to accommodate all qualified students in the class.
  8. For medical internships, incl. dental, school is responsible for insuring that student had a physical exam within 6 months before starting the internship, and all inoculations recommended in the profession.
  9. Provision for insuring the student against injuries resulting from the internship.
  10. Provision that students and instructors will be covered by liability insurance against liability for injuries/damage towards third parties (such as patients) arising from the internship. The insurance carrier, cost and exact insurance coverage must be identified.
  11. The school is responsible for providing all theory/practice instruction.
  12. The affiliation site will use the performance evaluation tool provided by the school.
  13. Students will be supervised at ALL times during affiliation time. For internships that do not involve HHA, Nurse Aide or Ultrasound, the staff person of the place of business will be identified to supervise the students.
  14. Provision for school visitation and/or oversight of the internship site.
  15. Provision for ensuring proper student conduct at the internship site.
  16. Provision for Specific conditions and procedures for terminating a student.
  17. Provision for either party to terminate the affiliation agreement.
  18. Provision for the language of the internship.  If the training was in a language other than English, the affiliation school must ensure that the internship site has employees and clients conversant in that language with which the intern will work.
  19. Every affiliation agreement must refer to an attached skills checklist, whose skills students must demonstrate during the internship.  The school must attach the list to the affiliation agreement. Care must be taken, e.g. for allied health, that the skills do not cross professional boundaries.

Sample Affiliation Agreement