BPSS-31 Updated: Affiliation Agreement for Internship Sites

Click here to download updated affiliation agreement BPSS 31


An affiliation agreement must be submitted and approved for each internship. The following information/conditions must be included in the agreement. You can choose to use the sample agreement below. A separate agreement exists for Nurse Aides.

  1. Specific name and location of the proprietary school
  2. Specific name and location of the internship site AND a photocopy of its license
  3. Exact dates/or length, of the affiliation experience
  4. Number of students to be supervised during one affiliation period
  5. Who is responsible for taking attendance at the affiliation site
  6. tudents will not displace or replace regular employees
  7. he 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. School or Externship site (usually the school) is responsible for insuring the student against injuries resulting from the internship. [The school either buys an 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, the name of the company, the cost to students, and the extent of coverage, must be noted in the Externship Agreement].
  10. Students and instructors will be covered by liability insurance against liability towards third parties arising from the externship. 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
  14. How often the program coordinator will visit the affiliation
  15. The school is responsible for the conduct of the students at the affiliation site
  16. Specific conditions and procedures for terminating a student
  17. How much notice must be given by either party to terminate the agreement

Sample Affiliation Agreement

Name of School: _____________________________________________

Address of School: _____________________________________________


Name of Facility: _______________________________________________

Address of Facility: ______________________________________________

The (name of school) has been approved to conduct a (name of program) training program which requires clinical experience in a nursing facility. The (name of facility) has agreed to provide this supervised clinical experience. Therefore the internship facility, now referred to as the affiliating institution, and the school, enter into the following agreement:

The school will arrange for a maximum of ___ students to affiliate at (name of affiliating institution) for a period of ___ hours/days. The specific hours/days will be agreed upon by a designee of each party and each will keep a copy of the schedule. There will be no more than 10 students assigned to one clinical instructor. Taking attendance at the externship site will be the responsibility of the school. Students will not displace or replace regular employees at the affiliating facility. The school agrees to maintain sufficient affiliation sites to accommodate all qualified students.

(For medical internships only): Before the student begins the supervised clinical experience, he or she will show evidence of physical requirements deemed necessary by agreement of both parties. The school is responsible for insuring that the student has had a physical exam within six months, and all recommended inoculations, before the start of the internship.

(School/Affiliating Institution) is responsible for student injury acquired at the affiliation site. Students and instructors will also carry liability insurance and a signed statement indicating that they have a policy covering liability against third parties resulting from this internship.

Students will be under the supervision of the clinical instructor(s) employed by the school, but may also be supervised by the professional staff of the affiliating institution. The school is responsible for providing all theory/practice instruction. Students will have received the necessary classroom and clinical instruction from the school before being authorized to perform patient care. The clinical instructor(s) will make assignments and, with the help of the professional staff of the institution, will evaluate each student’s performance using the evaluation instruments provided by the school.

The clinical instructor will be present at all times students are present. The school’s program coordinator will make (frequency) visits at the externship site.

The school is responsible for the conduct/dress requirements of the students at the affiliation site. A student who does not satisfactorily meet the requirements of this externship may be terminated. Prior to termination, the student will be notified of these deficiencies and will be given (x) days to correct these deficiencies.

The school recognizes that the affiliating institution has a service responsibility to its clients. If a student jeopardizes this responsibility in any way, the affiliating institution has the right to demand that the student be removed from the clinical experience immediately.

The agreement will begin on (month/day/year) and will be reviewed annually by both parties before the agreement is renewed. A (Length of time) notice will be given by either party if the agreement will not be renewed. Both parties agree to contact the Bureau of Proprietary School Supervision immediately upon requesting termination of the contract.

The affiliating institution and the school will not discriminate in any way in regard to student learners, according to state and federal laws.

_____________________________________ _____________
Affiliating Institute Representative, Name/Title Date

______________________________________ _____________
School Representative, Name/Title Date