APPENDIX F#    – Field Internship Institutional Data Form

Complete as many of these forms as necessary to report data on all field internship affiliates. 
A file with a blank form is available on the CoAEMSP web site.( )
Insert the file(s) of supplemental forms at the end of this Appendix.

Continuing Accreditation Self Study Report (CSSR)                               AFFILIATE #: [    ]
Chief Administrative Officer:     
Telephone #:               
Distance from the location of the program:                                   [       ] miles            [       ] minutes travel
Is there a signed, current agreement with this affiliate?             [  ] Yes                   [  ] No
Who supervises the students?          [  ] field agency personnel                [  ] program personnel
Are there written policies as to what students may do in each area?       [  ] Yes                  [  ] No
Are the preceptors formally trained?               [  ] Yes                  [  ] No
                                Or how many hours?        
Is there on-line medical direction for this affiliate?                      [  ] Yes                   [  ] No
Does this affiliate provide Advanced Life Support?                    [  ] Yes                   [  ] No
Is there a quality improvement program that reviews runs?      [  ] Yes                   [  ] No
# of runs per year  
# of active EMS units (excluding backups)  
# trauma calls per year  
# critical trauma calls per year  
# pediatric call per year  
# cardiac arrests per year  
# cardiac calls (less cardiac arrest) per year  
# Shifts per student  
average # runs per shift for a student  
# hours per shift