Dental Affiliation Agreement Requirements

(BPSS-31, updated 11/2014)

An signed affiliation agreement must be submitted and approved 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 other types of internship.

  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. The internship host must be located in New York State.
  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. Who is responsible for taking attendance at the affiliation site.
  6. 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. School is responsible for ensuring that student had a physical exam within 6 months before starting the internship, and all inoculations recommended in the profession.
  9. School or Internship site (usually the school) is responsible for insuring the student against injuries resulting from the internship. [If the school insurance does not cover the internship site, then the school either buys insurance for interns and rolls that insurance into the tuition, or makes available to interns the purchase of such insurance coverage. In the latter case, that students must buy their own accident insurance must be noted in the enrollment agreement, and the name of the company, extent of coverage, cost to students noted in the Affiliation Agreement].
  10. Your 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 tools provided by the school.
  13. Students will be supervised at ALL times during affiliation time. The staff of the place of business will usually supervise the students.
  14. How often the program coordinator will visit the internship site.
  15. The school is responsible for the conduct of the students at the internship site.
  16. Specific conditions and procedures for terminating a student.
  17. How much notice must be given by either party to terminate the agreement.
  18. If the training was in a language other than English, the affiliation institution must declare that the internship host has employees and clients conversant in that language for the intern to work with. This must be added to the text.
  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. The skills checklist must be first approved by BPSS. 20. Internship host pledges that interns shall not perform tasks determined by the New York State Education Department, Office of the Professions (OP), as being restricted to students in a Certified Dental Assistants program registered by OP. These tasks are listed on the OP webpage.

Sample Affiliation Agreement