E-Surveymaker.com

Willingness to Serve as a PPE Clinical Site

Thank you for your willingness to serve as a Clinical Site for HIM Students. Please complete the following information which will be kept in a central database and shared with Program Directors of Ohio CAHIIM-accredited HIM programs needing to place students in clinical sites.

After completing the survey, no further action is needed on your part at this time. The Program Director(s) will contact you directly to discuss the possibility of placing their student in your facility if chosen.

^*1. Facility Name:

^*2. Facility Mailing Address:

^*3. Facility Zip Code:

^*4. Contact Name:

^*5. Contact E-Mail Address:

^*6. Contact Phone:

^*7. If a program requires a student to complete a project of some type, do you feel your site can usually offer the student that opportunity?

Yes
No

^*8. Do you have a preference for type of student?

Yes, I prefer a 2-year (HIT) student
Yes, I prefer a 4-year (HIA) student
No, I have no preference - will host either a 2-year or 4-year student

^*9. Clinical sites are needed during the academic year and sometimes during the summer months. Please indicate when you would be willing to accommodate a student on PPE. (check all that apply)

Fall
Spring
Summer
Anytime throughout the year
Other (please indicate if there is a definite time period when you would not be able to take a student).

^*10. How many students can you accommodate at one time for a PPE?

1
2
3
Other (please specify):

^*11. Can you accommodate one or more students rotating through your facility on a weekly basis?

Yes (please indicate how many):
No

^*12. Can you accommodate one or more students who must complete full time PPEs for a week or more at a time?

Yes (please indicate how many):
No

13. If there are any specific skills or qualifications that you'd like the student to possess, please indicate:

14. Does your facility have any special requirements for H&P, immunizations, background check (fingerprinting etc.)? If yes, please indicate requirements:

15. Comments (optional):