1.  Agency Name:       

2.  Department Name: 

3.  Address     

City, State, Zip 

4.  Please list other universities which have students in Recreation, Parks and Tourism or a similar academic program that are currently affiliated with your agency/department.

5.  Enter the time of the year that students do their internship in your agency/department: (check all that apply)  

Fall

Spring

Summer

6.  Check the number of students the agency/department usually accepts during a semester or a summer.

1 or 2

3 or 4

5 or more

7.  Check the activity areas your agency/department offers as program of services.  (check all that apply)

Arts and Crafts

Dance

Music

Games

Sports and Athletics

Drama

Outdoor

Special Events

8.  List any special programs or services your agency/department offer.

9.  If you offer special programs for the disabled, are they directed toward a specific disability group?  (check all that apply)

Physical Disabled

Learning Disabled

Mentally Retarded

Emotionally Disturbed

Visually Impaired

Hearing Impaired

10.  Would the student have the opportunity to complete one or more special projects as recommended or required by the 

agency/department?  

Yes    No

university?

Yes    No

11.  Enter the number of staff in your department.

12.  Indicate the percentage of student participation in any of the following experiences.  (Total should equal 100%).  

Administrative Duties:          %

Supervisory Duties:              %

Budgeting:                            %

Committee Meetings:            %

Public Meetings:                    %

Clerical Duties:                      %

Management Duties:              %

Maintenance:                         %

Group Leadership:                 %

Special Projects:                    %

Department Meetings:            %

Board Meetings:                     %

Programming:                          %

Diagnostic Team Meetings:      %

Treatment Team Meetings:       %

Individual Client Services:        %

Marketing Duties:                    %

Evaluation:                              %

Recreation Education:              %

Planning Duties:                       %

Other:                                      %

Assessment/Screening               %

Individual Client Treatment Planning    %

13.  Does your agency/department have a designated staff member responsible for coordinating student internship experiences?

Yes

No

Please enter their name and telephone number

If a therapeutic recreation setting, please indicate CTRS Qualification Number

14.  If answer to #13 is no, how is the student's internship coordinated within your agency/department? (explain)

15.  Does your agency/department reimburse (financially, housing, travel, etc.) the student in any way for internship?  

Yes

No

If Yes, explain.

16.  If your agency meets the requirements for therapeutic recreation enter their name and  certification number.

17.  If applicable, how do you implement the therapeutic recreation process model?

The individual completing this questionnaire is:

Name: 

Title:

Address:

Phone Number:

Fax Number:    

Email address   

Homepage Address:

If applicable, name of student requesting this information