Dental Affiliation Agreement Requirements

(BPSS-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 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. 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. 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. 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 affiliation internship site will use the performance evaluation tools provided by the school.
  12. Students will be supervised at ALL times during affiliation time. The staff of the internship site will supervise the students.
  13. Provision for school visitation and/or oversight of the internship site.
  14. Provision for ensuring proper student conduct at the internship site.
  15. Provision for Specific conditions and procedures for terminating a student.
  16. Provision for either party to terminate the affiliation agreement.
  17. 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.
  18. 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 approved by BPSS as part of the curriculum approval process. 
  19. Assurance 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