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					                                                  [TEMPLATE]

                                REPORT OF A SITE VISIT
                                                         TO

                                     [INSERT NAME OF INSTITUTION]

                  [INSERT INSTITUTION LOCATION (e.g., SAN FRANCISCO, CA)]

                                          [INSERT DATES OF VISIT]


                                                       For the

                                           Accreditation Commission for
                                         Acupuncture  Oriental Medicine




                                           SITE VISIT EVALUATION TEAM

                                             [LIST SITE VISITORS HERE]

                                      (Example: Ronald Smith, L.Ac., Chair
                                     Willowbark College of Oriental Medicine
                                                 Mainline, MO)




This report represents the views of the evaluation team as interpreted by the Chair; it is submitted directly to
the institution before being considered by the Commission. It is a confidential document prepared as an
educational service for the benefit of the institution. All comments in the report are made in good faith, in an
effort to assist the institution. This report is based solely on the team's educational evaluation of the institution
and of the manner in which it appears to be carrying out its educational objectives."
BACKGROUND

 Briefly describe any relevant background information, including:

       Institution name and any changes in institution name
       Location of main campus and branch campus (if applicable)
       When the institution was originally established
       Whether the institution is authorized to operate or grant degrees in the state where the program is located
        and the name of the state agency, which granted the authorization
       The legal structure of the organization (for-profit/non-profit corporation, partnership, etc.)
       Any changes in legal status (e.g., from sole proprietorship, partnership to corporation, or vice versa)
       Any changes in tax status (e.g., from for-profit to non-profit)
       Accreditation history and status with other accrediting agencies, if applicable
       Types of programs offered (e.g., Oriental Medicine)
       Number of students in the program, and the languages (e.g., Korean, Chinese, English) in which the program
        is offered.
       Accreditation history with ACAOM (e.g., “The school was initially granted ACAOM candidacy status in 1992.
        The school received full ACAOM institutional accreditation in 1993, was reaccredited in 1996, 2000 and then
        in 2006 for a three-year period.”)

SUMMARY OF THE VISIT

   Briefly describe the visit.

    Example:
    During the four-day review of the school, the site visitors interviewed many faculty members, key
    administrators, a large number of students and graduates, and the Board of Trustees. Briefly describe
    confidential interviews, if any (e.g., The visitors also interviewed a few students in the English program who
    met with the team for a private interview.) The visitors also reviewed student, faculty, financial, governance,
    curriculum and clinical records as well as faculty minutes, board bylaws and minutes and policy manuals and
    handbooks. The team also reviewed both campuses and observed clinical and classroom instruction. At the exit
    interview, the Site Visitors conveyed the general outline of this report to the President, and others whom the
    President invited to attend the interview. The site visitors assured the school representatives that they would
    have an opportunity to correct any errors of fact, which might appear in the report. The school representatives
    were advised that, consistent with the Accreditation Procedures, the site visitors would provide its
    recommendations regarding reaccreditation to the Commission alone.

I. PURPOSE

 Briefly describe and assess the statement of purpose of the institution/program relative to compliance with ER
    1 and Criterion 1.1.

    Example:
    The school’s statement of purpose is “to offer educational programs in the four-millennium old, clinically
    proven, time-tested and internationally-recognized discipline of Traditional Oriental Medicine (TOM) so that its
    students can acquire the professional competencies necessary for the successful practice of Oriental medicine.”
    The statement of purpose appears to provide appropriate direction for the institution and its programs.

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    FINAL SITE VISIT REPORT TEMPLATE - AUGUST 2007
   Example:
   Although the institutiton/program’s mission and statement of purpose generally meet ACAOM standards, a
   number of elements of the mission statement are not adequately reflected in the program’s published goals.
   [Explain]

 Briefly describe and assess the educational objectives of the program relative to compliance with Criterion 1.2.

   Example #1:
   The program's educational objectives are to enable its graduates to: 1) pass the California licensure and
   NCCAOM certification exams; 2) acquire a sufficient knowledge of Oriental medicine theory to be effectively
   applied in a clinical setting; 3) demonstrate knowledge, competency and skills in the effective diagnosis,
   treatment planning and treatment of patients; 4) set up and manage a successful practice; 5) acquire sufficient
   knowledge in the western medical sciences to recognize medical conditions that may warrant patient referral to
   other appropriate medical providers; etc... The educational objectives are clear, measurable, and are each
   framed in terms of the competencies expected of students in the program. They provide appropriate
   benchmarks for assessing program effectiveness relative to student learning outcomes.

   Example #2:
   The program’s Educational objectives are measurable and appropriate to an Oriental medicine program. They
   provide appropriate benchmarks for assessing program effectiveness in relation to student learning outcomes.
   The college has strengthened its research activities (e.g., student theses requirements) offered in the program to
   ensure that the program’s graduates will achieve the 8th and 9th educational objectives.

   Example #3:
   Although the program has an appropriate statement of purpose, it is critical that the school adopt appropriate
   and measurable educational objectives that are framed in terms of the competencies expected of graduates
   from the program. Such objectives are critical if the school is to have appropriate benchmarks for assessing
   program effectiveness and documenting the achievement of appropriate student learning outcomes. Currently,
   the school has no officially adopted and published educational objectives.

   Example #4:
   The program must strengthen its educational objectives. Most/some are framed as institutional goals rather
   than appropriate educational objectives. Educational objectives must each be framed in terms of the
   measurable competencies expected of program graduates and provide a solid basis for documenting student
   learning outcomes.

 Briefly describe and assess whether the statement of purpose and educational objectives of the
   institution/program are sufficiently supported by program resources and are being achieved by the program.
   (Criterion 1.3)Example #1:
   The college’s statement of purpose and educational objectives are sufficiently related to the field of
   acupuncture/Oriental medicine and to the school's programs, resources, services and activities with the
   exception of the research component, which needs some strengthening.

   Example #2:
   Although the statement of purpose and educational objectives are appropriate and generally meet ACAOM
   standards, there is evidence that the objectives are not being fully achieved. For example, educational objective
   #4 requires students to be competent in Oriental medicine research, but the portfolios of student work
   reviewed by the team reveal that students are not achieving competencies in OM research.


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 Briefly describe and assess whether the statement of purpose and educational objectives are reviewed by the
    institution/program’s relevant communities of interests, and revised when necessary (Criterion 1.4)

    Example #1:
    A review of faculty, administrative staff, and Board meeting minutes provides evidence that the school‘s
    statement of purpose and educational objectives are regularly reviewed and revised by relevant school
    constituencies when needed. Students are generally aware of the school’s statement of purpose and
    educational objectives.

    Example #2:
    There is no evidence that the statement of purpose and educational objectives are reviewed by relevant school
    constituencies and revised when necessary. [Explain].

 List findings of the team for each relevant standard: (e.g., Compliance, Non-Compliances, Areas Requiring
    Further Development:

    ER 1 – Compliance.....

    Crit. 1.3 – Area Requiring Further Development....

    Etc. …

II. LEGAL ORGANIZATION

 Briefly describe the legal structure of the institution, authorization to operate and eligibility of its graduates
    for licensure.

    Example:
    The XYZ College of OM is an Ohio non-profit, public benefit corporation, which is exempt from taxation under
    section 501(c)(3) of the Internal Revenue Code. The school has been approved to operate as a degree granting
    educational institution by the Ohio Board of Education and is approved by the Board to offer the following
    programs: 1) Certificate in Acupressure-Tuina Massage; 2) Bachelor of Science in Holistic Science; and 4) Master
    of Science in Acupuncture and Oriental Medicine; and 5) Doctorate in Oriental Medicine.... The school meets
    the requirements of the Ohio Acupuncture Board for its graduates to become licensed in the state, as well as by
    NCCAOM for graduates to sit for the national certification exam.

    If applicable, briefly describe the institution’s status and/or history with other accrediting agencies:

    Example #1:
    From 2000 to 2001 the school was accredited by the Accreditation Commission for Continuing Education and
    Training (ACCSET), but lost its accredited status with ACCET when the school achieved degree-granting authority
    since ACCSET will not accredit degree-granting institutions.

    Example #2:
    The college is currently pursuing regional accreditation with Middle States and in Spring 2003 was granted
    eligibility to pursue candidacy and accreditation for programs at the Bachelor’s and Master’s-level, but not at
    the doctoral level.

 Briefly describe and assess program compliance with relevant state, federal and local laws and regulations
    applicable to its operations.

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  Final Site Visit Report Template - AUGUST 2007
    Example #1:
    The institution appears to meet all relevant state, federal and local laws and regulations applicable to its
    operations.

    Example #2:
    Although the school, for the most part, meets relevant state, federal and local laws and regulations applicable to
    its operations, a few concerns are noted in this area. First, the school does not currently comply with the Health
    Insurance Portability and Accountability Act (“HIPAA”) in that it has failed to.... The program must take
    appropriate steps to achieve full compliance with HIPAA....

    Example #3:
    Although the school, for the most part, meets relevant state, federal and local laws and regulations applicable to
    its operations, a critical deficiency relates to the program’s non-compliance with OSHA requirements. In this
    regard, the following deficiencies are noted....

 Briefly describe and assess institutional controls for off campus educational activities relative to compliance
    with Criterion 2.1.

    Example #1:
    The program includes several off-campus clinics where some training takes place. There is evidence that the
    program is monitoring the training at these sites to ensure that the quality of training is equivalent to clinical
    training conducted by the school’s on-site clinic. The team finds that learning experiences and outcomes at
    these locations are consistent with those at the main campus clinic.

    Example #2:
    The program conducts some clinical training at 2 off-campus clinics. However, the program has not
    implemented proper oversight mechanisms to ensure quality of training. Currently, students are placed in the
    clinics of private practitioners. The Clinic Director is not providing adequate oversight of the training and was
    unable to demonstrate to the team’s satisfaction that the program was documenting student learning outcomes
    at these off-campus clinics.

 Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliance, Area Requiring
    Further Development):

    ER 2 – Non-Compliance: ....

    Crit. --2.1 – Area Requiring Further Development: .......

III. GOVERNANCE

 Briefly describe and assess the governance structure of the institution, including the composition and
    qualifications of the governing and advisory board (if applicable) and the number of public members vs.
    institutional members relative to compliance with Essential Requirement 3).

    Example #1:
    Governance is a substantial strength of the college. The Board is qualified, engaged, and is clearly providing
    effective leadership for the institution. The governance of the school consists of a nine member Board of
    Trustees that is responsible for the affairs of the school. The school’s governance structure does not include an
    Advisory Board. The Board of Trustees includes eight public members and the college President of the school
    who serves ex-officio, without a vote. Board members are well qualified and possess a variety of valuable
    backgrounds and experiences, including individuals with backgrounds in higher education, Oriental medicine
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  Final Site Visit Report Template - AUGUST 2007
   practitioners, businessmen, a pharmacist, and educators in other fields. As noted below, it is clear that the
   governance structure is providing effective leadership for the institution and its programs.

   Example #2:
   The governance structure of the school is comprised of a 3-member Board of Directors comprised of the school’s
   founders who also serve in the school administration. To ensure representation of the public interest, the
   school also has a 6-member Advisory Board, comprised of public members with broad backgrounds, which
   makes recommendations to Board of Directors on all matters concerning the governance of the institution.
   Members of the Board of Directors and Advisory Boards appear qualified and the governance structure is
   fulfilling its roles and responsibilities.

   Example #3:
   The governance structure is composed of a 7 member Board of Directors (i.e., two shareholders, 3
   administrative staff, one faculty member and one alumni of the program). Public representation is lacking in the
   governance structure of the institution.


 Briefly describe and assess whether the governance structure is effectively representing the needs of the
   institution’s communities of interest.

   Example #1:
   One faculty member and one student liaison participates in meetings of the governance structure to provide
   input to the Board of Directors. Program faculty and students interviewed by the team indicate that their views
   are effectively represented in Board deliberations through this process.

 Briefly describe and assess the functioning of the governance structure relative to compliance with Essential
   Requirement 3/Criterion 3.2)

   Example #1:
   Meeting minutes of the Board indicate that the Board is fully involved in governing the affairs of the school in
   most relevant areas, including oversight of the school’s finances, reviewing and approving the school’s mission
   statement, oversight of the school’s programs, approving major policies and procedures, approving major school
   decisions, and evaluating the performance of the school President. However, it is important that the Board
   develop and implement a long range strategic plan to ensure adequate resources for well planned institutional
   development.

   Example #2:
   Board functioning must be strengthened. There is insufficient evidence that the Board is functioning in relevant
   areas, including providing proper oversight of the school’s finances, reviewing and approving the school’s
   mission statement, oversight of the school’s programs, approving major policies and procedures..... The recent
   fiscal crisis at the program and the existence of school policies and procedures that do not meet accreditation
   requirements demonstrates that the effectiveness of the Board must be improved.

   Example #3:
   Although the Board of Trustees is fully functioning in all relevant areas appropriate to a governing board, the
   Advisory Board is not sufficiently proactive in providing input into all areas relevant to the governance of the
   institution. Given that this seven member Board has only one public member, effective public input on all key
   governance functions is lacking. If the institution intends for the Advisory Board to represent the public interest
   in the governance structure , the Advisory Board must be fully engaged in ....


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 Briefly describe and assess whether the governance structure possesses bylaws consistent with the
   requirements of Criterion 3.3.

   Example #1:
   The Board Bylaws are deemed appropriate and fully meet the Commission’s standards. They clearly specify the
   Board’s composition, meeting and membership requirements, terms of office, responsibilities to the program as
   well as Board powers and duties, including the Board’s ultimate authority over the affairs of the school.

   Example #2:
   The Board Bylaws need strengthening. Although they describe the powers and duties of the Board, they do not
   adequately describe membership requirements and terms of office.

   Example #3:
   Although the Board of Directors Bylaws are appropriate and fully meet Commission requirements, appropriate
   Bylaws must be adopted for the Advisory Board. Advisory Board Bylaws do not articulate the Advisory Board’s
   roles and responsibilities and lack provisions on composition and meeting requirements. This is evident from a
   review of the Advisory Board meeting minutes, which indicate that the Board is not providing input key areas
   relevant to governance functioning including….

 Briefly describe and assess whether governance meetings are sufficient, and whether governance records
   (agendas and minutes) are adequate relevant to Criterion 3.4.


   Example #1:
   The Board of Directors and Advisory Boards meet at regularly stated times. As a result of the Self-Study process,
   the Board has strengthened its Board meeting minutes to more accurately document Board’s actions
   consistent with ACAOM standards. In addition, agendas are in evidence for each Board meeting, and minutes
   are appropriate with adequate supporting information to fully document Board actions and decisions.

 Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliances, Areas
   Requiring Further Development):

   Criterion 3.2 – Non-Compliance.....

   Criterion 3.4 – Area Requiring Further Development .....

IV. ADMINISTRATION

 Describe and assess the adequacy of the administrative infrastructure, the administration and their
   qualifications, including the effectiveness of the chief administrator relative to compliance with Essential
   Requirement 4, Criterion 4.1 and Criterion 4.2. In assessing qualifications of staff, focus the review on
   administrative effectiveness/outcomes and whether staff are capably performing their roles and
   responsibilities.

   Example #1:
   The Institution has a well-organized administrative team that is more than adequate for the needs of the school.
   Job descriptions and the organizational chart are comprehensive and complete and fully reflect the
   administrative infrastructure at the institution. The administration is well qualified and, with limited
   exceptions, has an excellent handle on administrative operations, as reflected in the superb condition of school
   records, effective administrative systems, etc. The administration also works extremely well as a team, with
   effective and regular communication occurring among senior staff. The levels of communication at all levels of
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   the administration have ensured that administrative changes, initiatives, policies, procedures and operations are
   known by all relevant staff and are properly coordinated for effective and efficient implementation.....The
   President’s energy, commitment to, and vision for the school has provided effective leadership for the school in
   fulfilling its mission. The President is involved in managing the school’s administrative affairs, with the effective
   assistance of other members of the administrative leadership. The administrative team is composed of: a
   President; Assistant to the President; Dean of Administration; Personnel Director, Director of Finance; Academic
   Dean; Director of Admissions; Fiscal Officer; Financial Aid Director; Registrar; campus Librarians; Director of
   Clinics; Program Coordinator; and a significant number of support personnel.

   Example #2:
   The administration is composed of a school President, Registrar, Librarian, Academic Dean, Admissions Director,
   Clinic Director, Clinic Manager, and Business Manager. The administrative structure needs some strengthening.
   Although the President is a prominent practitioner, she does not have adequate expertise in higher education
   administration as reflected in administrative management deficiencies in the following areas...... Since staff job
   descriptions are unclear as to reporting lines, job duties appear to overlap with other administrative positions,
   and the organizational chart does not reflect the actual administrative structure. Staff are unclear as to their
   responsibilities within the program and are not effectively performing all critical administrative functions for the
   institution. This is reflected in problems with the school’s record keeping functions (See Records), admissions
   deficiencies (See Admissions), and student and program Assessment (See Assessment). Key members of the
   administrative team do not appear sufficiently qualified to fully perform their responsibilities, particularly with
   respect to the Registrar and Admissions functions (See ER 6). The program should consider conducting in
   service training for administrative staff or hire individuals who have adequate higher education administrative
   experience. The deficiencies in administrative functioning provide evidence that the President is not providing
   sufficient leadership for the administration and that administrative staff do not fully understand their roles and
   responsibilities.

 Briefly describe and assess the effectiveness of the structure for academic leadership and whether the
   academic leadership team is performing at an adequate level consistent with Criterion 4.3. Address
   specifically the effectiveness of the process for curriculum development and program assessment
   implemented by the academic leadership team.

   Example #1:
   While the school does have a clearly defined structure for academic leadership, including an Academic Dean,
   Dean of Clinical Affairs and language track Program Directors for both campuses and possesses adequate
   processes for curriculum development and program assessment, academic leadership in general needs
   strengthening and training to ensure that: students take courses in sequence consistent with required course
   prerequisites (See Admissions); students are more adequately prepared to take the NCCAOM certification exam
   given the low pass rates of graduates; faculty course assignments more fully match faculty qualifications and
   areas of expertise (See Faculty); and that key faculty policies are adequately communicated to faculty (See
   Faculty). In addition, the program needs to strengthen academic leadership for clinical training at the XYZ
   campus. The Acting Clinical Director for XYZ campus is also the English Program Director for the campus and
   has significant additional teaching duties. With all these responsibilities combined, the FTE for the Acting
   Clinical Director exceeds a reasonable full time load as reflected in the deficiencies noted in this report under
   clinical training (See Program of Study).

   Example #2:
   The Academic leadership team is effective and is competently performing all key academic leadership functions
   for the institution, including program assessment, documenting student learning outcomes, faculty evaluation,
   among others.

   Example #3:
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   Although the school does have a clearly defined structure for academic leadership, key members of the
   academic leadership team, including the Clinical Director and Academic Dean are recent graduates from the
   program and do not have adequate credentials and experience to fully perform all key academic leadership
   functions. These deficiencies are noted in a number of areas. For example, the program has yet to implement
   an effective system for curriculum development and program assessment and the deficiencies in the curriculum
   and in clinical training (See Program of Study) demonstrate a clear need to strengthen academic leadership.

 Briefly describe whether the program conducts its operations with honesty and integrity (e.g., not misleading
   the public, students or prospective students, not engaging in any forms of dishonesty, treating members of the
   college community fairly, etc...).


   Example #1:
   There is no evidence that the program does not conduct its operations with honesty and integrity.

   Example #2:
   The program catalog and advertisements make inaccurate representations about the program. Since the
   program has not yet achieved ACAOM candidacy, the statement in the catalog that program graduates are
   eligible to sit for the NCCAOM certification exam is inaccurate.


 Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliance, Areas
   Requiring Further Development ):

   ER 4 – Non-Compliance

   Criterion 4.3 – Area Requiring Further Development...


V. RECORDS:

 Briefly describe and assess the recordkeeping systems of the institution/program, including student academic
   records) and whether they are accurate, complete, secure and maintained as confidential (ER 5/Criterion 5.1).

   Example #1:
   The program’s maintenance of school records is a substantial strength. School records of all types (e.g.,
   admissions, financial, Board, curriculum, faculty records) are accurate, complete, well organized and
   scrupulously maintained. Records are kept in locked, fireproof cabinets and are securely maintained to protect
   confidentiality. Student academic and admission files are, with few exceptions (See Admissions), complete and
   well maintained by relevant members of the administration. Student files include: a completed admissions
   application; official transcripts; transfer credit evaluation forms; admissions evaluation form which tracks prior
   education, general education requirements and English language competency); appropriate records of foreign
   student eligibility such I-9's and VISA status; SSN cards (if applicable); student photo; admissions
   recommendations; admissions acceptance letter; and relevant policy statements signed by the student (e.g.,
   Drug-Free Policy, Student Rights Policy, FERPA policy acknowledgment, etc.). The files also include grade report
   transcripts by quarter (full grade reports for the entire program are maintained on computer), statement of
   student financial accounts; CCAOM CNT course completion; enrollment agreement; and miscellaneous
   correspondence and forms (e.g., leave of absence, make up exam forms, request letters to supply missing
   information/documentation), etc. Currently, the school does not have a written plan for the storage of
   permanent student records in the event of closure of the program. Such a plan should be developed. Faculty
   files, which are maintained by the school’s Personnel Office, are well organized and generally complete with
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    CV’s, I-9's, faculty evaluations and other relevant documentation. However, there were isolated incidents where
    some files contained expired licenses and were missing I-9's.

    Example #2:
    School records need substantial improvement. Student academic files are incomplete and lack key
    documentation needed to document student learning outcomes such as.... Files are not maintained in a
    manner, which ensures their security. File cabinets are unlocked and are located in areas accessible to students
    and members of the public. Faculty records are incomplete with many lacking CV’s, professional licenses, I-9's
    and other relevant documentation. Financial records are in disarray, with the following deficiencies noted.....

 Briefly describe and assess the accuracy, security and completeness of clinic patient records (Criterion 5.2)

    Example #1:
    With limited exceptions, clinical records were found to be secure and complete. Clinical records include the
    patient history, progress notes, signed informed consent forms, etc.. All observed patient chart entries are in
    English and were consistently signed by interns and co-signed by clinical supervisors. Although patient files are
    generally in superb condition, the team noted that for a number of patients for whom there were multiple clinic
    visits with a variety of changing signs and symptoms over time, there was no change in the patient assessment
    that would be warranted by the new medical conditions and symptoms. Patient histories were also observed to
    be somewhat minimal in a few patient files. These issues are addressed further under the Program of Study
    section of this report. Patient files are securely maintained in locking, fireproof cabinets, which are overseen by
    the Clinic Manager.

    Example #2:
    Clinic records need substantial improvement. Many files do not include informed consent forms signed by the
    patient, patient chart entries are often unsigned and are not co-signed by clinical supervisors, and SOAP charting
    is non-existent for many patient files. Chart entries are often in Korean/Chinese, which makes the files
    inaccessible for students in the English program. In addition, the program needs to strengthen its patient
    intake form, which fails to list patient allergies and medications – which is critical given the health safety
    implications for prescribing herbs to patients.

 Briefly describe whether the program maintains and uses data required under Criterion 5.3 (i.e., student
    profiles showing the number of students enrolled, graduated, and readmitted; admissions data showing the
    number of applications received vs. accepted for admissions, and the ages, sex, educational backgrounds, and
    racial origins of the student body).

    Example #1:
    Data collection and maintenance are strengths. The school has a well-developed and maintained computer
    database for tracking student admissions, financial and academic information as well as compliance with the
    school’s English language competency requirements including TOEFL and TSE scores. The Registrar is responsible
    for maintaining academic and admission records and is responsible for tracking enrollment, admissions and
    relevant student demographic data. The school tracks and maintain various data, and there is evidence that the
    data is routinely analyzed as part of the institution’s process for program assessment. All data required under
    Criterion 5.3 are appropriately tracked, compiled and maintained.

    Example #2:
    Although the program collects all the data and statistics required under Criterion 5.3, there is no evidence that
    these data are used to assess program effectiveness and outcomes (See Assessment).

    Example #3:

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  Final Site Visit Report Template - AUGUST 2007
   Although the program tracks admission data, the program must maintain appropriate student demographic
   information required under this standard.

 Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliance, Area Requiring
   Further Development):

   Compliance

   Area Requiring Further Development
   Etc…

VI. ADMISSIONS:

 Briefly describe and assess admission policies, procedures and practices of the program relative to compliance
   with Essential Requirement 6.

   Example #1:
   Admissions policies and procedures are, for the most part, appropriate and consistently enforced. They
   generally result in a body of matriculated students who are adequately prepared to undertake a rigorous
   Oriental medicine program at the Master’s level. Primarily the Admissions Director, working with Academic
   Dean, collaborate in coordinating the admissions process and making admissions decisions. The Registrar is
   responsible for some of the administrative aspects of the admissions process and for maintaining admissions
   files. Prospective students seeking admission to the program must submit an admissions application, certified
   academic transcripts of prior education sent directly by the academic institution to the school, a non-refundable
   application fee, and letters of recommendation. Foreign students must further provide a F-1 student visa (if
   applicable), and proof of English language competency (see below). Foreign students who cannot produce
   official transcripts at the time of matriculation in the program, may submit copies, but official transcripts must
   be submitted within one quarter for students to enroll in the subsequent quarter. The one-quarter limit for the
   submission of official transcripts is being properly enforced. Although school policy requires that foreign
   transcripts must be confirmed and authenticated through a report from a foreign credentials evaluation service,
   a few admission files for foreign students lacked this required documentation. The program reviews the
   admissions documentation for completeness and conducts an admissions interview with each prospective
   student. The documentation and admissions interview provide the basis for an admissions decision. The
   school’s admissions policy requires 60 semester credits or 90-quarter credits of accredited college education.
   The admissions policy meets ACAOM standards.

   Example #2:
   Although the program’s admissions policies, procedures and practices appear to meet ACAOM standards, the
   program must ensure that the policies and procedures posted on its web site are consistent with the Catalog
   and with ACAOM requirements. Although the catalog version of the policy meets ACAOM standards, the web
   site version does not. In particular, the web site version inappropriately requires “...2 years earned at accredited
   institutions or at institutions accredited and/or approved as degree-granting Postsecondary institutions or the
   equivalent (Emphasis Added). The highlighted language does not meet ACAOM standards. However, there is no
   evidence that the program has actually admitted students that do not meet appropriate admissions standards.

 Briefly describe and assess the prior learning assessment policies and practices of the program and whether
   they meet Criterion 6.1.


   Example #1:

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      The program does not accept prior learning assessment as part of meeting program admission requirements.
      All student applicants must meet the program’s 60 semester/90 quarter credit entrance requirements.

      Example #2:
      Under the program’s published admission’s policies, the program will accept standardized tests such as CLEP and
      the College Scholarship Service’s AP exams to meet part of the required two year entrance requirement. These
      policies are fully consistent with ACAOM requirements and are being enforced.

 Briefly describe and assess the transfer credit policies, procedures and practices of the program and whether
      they meet Criteria 6.2 & 6.5.

      Example #1:
      The school’s policy for awarding transfer credit published in the catalog meets ACAOM standards. The
      Academic Dean evaluates transfer credit by analyzing and documenting prior course work on a transfer credit
      work sheet based on a review of prior transcripts and catalog course descriptions or syllabi of the applicant’s
      prior course work. This documentation is reviewed to ensure the equivalency of prior course content to
      program courses prior to awarding transfer credit. The use of challenge exams are considered when there are
      questions or doubts as to whether prior course work is similar to courses offered at the program. The school’s
      policies and procedures for awarding transfer credit are appropriate and consistently enforced.

      Example #2:
      Although the program’s published transfer credit policies appear to meet Commission requirements, they are
      not properly enforced and implemented. The program must adopt reliable methods for ensuring that prior
      coursework is equivalent to courses offered in the program prior to awarding transfer credit. A review of prior
      college transcripts alone is insufficient for these purposes. The program also needs to cease its practices of
      awarding transfer credit based solely on “professional experience” or taking program challenge exams without
      having taken prior similar course work. Transfer credit should only be granted for prior course work, which is
      substantially similar to courses offered in the program. Under the program’s current practices, a review of
      student academic files reveals that a number of transfer students are having difficulty in achieving required
      program competencies.

     Briefly describe and assess the adequacy and completeness of the school’s admissions policies relative to
      Criterion 6.3.

      Example #1:
      The program’s admissions policies, including the school’s policies for evaluating transfer credit and prior learning
      assessment are clearly stated in applicable school publications.

      Example #2:
      Although the school’s admissions policies are published, they are not clearly stated and the catalog version of
      some policies is inconsistent with those published in the Student Handbook and on its web site (e.g., transfer
      credit, prior learning assessment).


 Briefly describe and assess the adequacy of the planning process of the program for developing and improving
      its admissions policies relative to Criterion 6.4.

      Example #1:
      The completeness and proper implementation of the program’s admission policies and procedures provide
      evidence that the program has been engaging in careful planning to ensure that its admissions policies are
      serving the needs and interests of its students.
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      Example #2:
      The problems identified in this report relative to the program’s admission’s policies, and their implementation in
      a manner inconsistent with ACAOM standards demonstrates that the program must engage further planning to
      ensure that its admissions policies, procedures and practices are serving the profiles, needs and interests of its
      students.

 Briefly describe and assess whether the program has developed and properly enforces appropriate course
      prerequisites consistent with Criterion 6.6.

      Example #1:
      The Academic Dean is responsible for approving student registration and enrollment in their courses each
      semester. Although the school lists appropriate course pre-requisites in course syllabi, a random review of
      student academic files revealed that many students are taking courses out of sequence in violation of the
      school’s own published prerequisites. Examples include Anatomy Lab and Endocrinology courses taken before
      A&P, advanced herb courses taken before OM Theory, Herbs before Pharmacology, etc.... Prerequisite courses
      were also taken concurrently with courses that require those very prerequisites. A review of academic records
      demonstrates that a number of students who are taking courses out of sequence are having difficulty in more
      advanced program courses. The program must not approve student semester registrations for courses that
      violate course prerequisite requirements. The program must clearly strengthen academic leadership in this area.


      Example #2:
      All students appear to be taking courses in sequence consistent with published course prerequisite
      requirements. The program appears to be in full compliance with Criterion 6.6.

      Example #3:
      The program must develop and properly enforce appropriate course prerequisites for advanced courses in the
      program. In particular, the following problems are noted....

 Briefly describe whether the program observes honest, ethical and legal student recruiting practices consistent
      with Criterion 6.7 (e.g., avoids misrepresentation of the program).

      Example #1:
      The program observes honest and ethical recruiting practices consistent with both legal requirements and
      Criterion 6.7.

     Briefly describe and assess the English language competency policies, procedures and practices of the
      program relative to Criterion 6.8.

      Example #1:
      The program is in full compliance with ACAOM’s English Language Competency requirements. The school has a
      well-developed tracking system for TOEFL and TSE for each student and the team could find no evidence that
      students in the Korean and Chinese programs were permitted to enroll in clinic without demonstrating
      competency in the English language. The program is consistently using the official ETS-scored version of both
      exams as part of its English language competency assessment process. Korean and Chinese student interns,
      without any notable exceptions, were observed by the team to have a sufficient command of the English
      language during student interviews.

      Example #2:

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      Although the school appears to have appropriate policies for English language competency consistent with
      ACAOM requirements, the policies are not being properly enforced. A review of files for foreign students
      provide no evidence that the program is properly tracking and documenting completion of TOEFL and TSE scores
      before Chinese students enter clinic and many Chinese interns could not communicate with the site visit team in
      English.

 Briefly describe and assess the policies, procedures and practices of the program for allowing non-
      matriculated students to take program courses relative to Criterion 6.9.

      Example #1:
      The program’s audit policies are consistent with Criterion 6.9 and are being properly enforced.

      Example #2:
      A number of non-matriculated students have been permitted to take advanced program courses on an audit
      basis without having taken prerequisites for those courses. Although the program policy for auditing program
      courses requires non-matriculated students who wish to take program courses to meet the program’s
      admissions requirements, they must also require enrollees to meet course prerequisites for those courses to
      ensure that student participation in courses does not adversely impact the quality of instruction.



      Example #3:
      Although the program’s audit policies appear to meet Criterion 6.9, these policies are not consistently enforced.
      Several audit students have not met the prerequisites for the courses in which they have enrolled.

 Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliance, Area Requiring
      Further Development):

      ER 6 -- Compliance.....

      Criterion 6.8 – Area Requiring Further Development....


VII. ASSESSMENT:

     Describe and document the policies, procedures and practices for assessing program effectiveness. Also
      describe and document the policies, procedures and practices of the program for assessing student
      achievement relative to compliance with Essential Requirement 7/Criterion 7.2)

      Example #1:
      The school consistently uses tests, quizzes, written, oral and practical exams and finals, preclinical exams,
      comprehensive exams, case studies, and student evaluations by clinical supervisors (including intern evaluation
      forms) to evaluate student progress throughout all stages of training. The evaluation of students in their
      didactic training appears to be a strength. The program’s student assessment instruments for didactic training
      were found comprehensive, complete and documented student achievement of all the professional
      competencies expected from an Oriental medicine program. Student performance in clinical training is
      evaluated through school clinic phase exams, graded case studies, and through quarterly evaluations of each
      intern by clinical supervisors. Although the performance of student interns observed by the team in clinic
      appears adequate, the program must develop phased clinical competencies where the competencies expected
      at each phase of clinical training are clearly articulated, and where those competencies are measured and

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   evaluated with appropriate clinical evaluation instruments. The program analyzes student outcome data to
   assess program effectiveness.

   Example #2:
   Although the program uses tests, quizzes, written, oral and practical exams and finals, preclinical exams,
   comprehensive exams, and case studies, some of the course final and midterm exams are not sufficiently
   rigorous and need strengthening. For example, the OM Theory courses.... Assessment of students in their
   clinical training is a substantial strength of the program. The program has adopted phased clinical competencies
   where the specific competencies expected at each phase of clinical training are clearly articulated and assessed
   for each intern based on quarterly clinical evaluations, which appropriately target the competencies expected at
   each phase of training. The program needs to more consistently consider student learning outcome data to
   assess program effectiveness. In particular, the program currently ……, but has not documented the uses of
   outcome data as part of its curriculum development and program assessment processes.

 Briefly describe and assess the policies, procedures and practices for assessing program effectiveness and
   whether/how the program assesses relevant outcome data to make informed decisions regarding needed
   changes to the program (Criterion 7.1). Also describe the policies, procedures and practices for reviewing
   program goals, objectives, training model and curriculum to assess their appropriateness in relation to the
   elements listed in Criterion 7.1.

   Example #1:
   The program has recently established a well developed system for curriculum development and program
   assessment where the program’s academic leadership reviews appropriate outcome data such as overall
   student performance on the program’s comprehensive exams, course grades, overall student body’s compliance
   with the school’s satisfactory academic performance standards, graduate performance on the national
   certification exam and the state licensure exam, patient satisfaction surveys, student surveys, and other relevant
   data to assess the effectiveness of the program as a whole. Now that a good system is in place, and now that
   relevant data has been collected and properly analyzed, it now must be actually applied to strengthen the
   program and curriculum.

   Example #2:
   The program must strengthen its process for curriculum development and program assessment. Although the
   program has an established structure for academic leadership, there is no evidence that the program has either
   examined its goals, objectives, and training model or adopted or implemented any systems for assessing the
   effectiveness of its training. The program needs to develop a systematic process for curriculum development
   and program assessment where the school’s academic leadership regularly assesses program effectiveness
   based on its review of relevant program outcome data and use this process to strengthen and improve training.


 Briefly describe and assess whether the program makes a systematic effort to survey its graduates on their
   professional career development and how well the program prepared them for professional practice. Indicate
   whether/how the program uses survey results as part of its program assessment process. (Criterion 7.3)

   Example #1:
   The program surveys its graduates on an annual basis to assess the success of their graduates in practice and to
   seek feedback on program effectiveness. Data from these surveys are compiled and used as part of the
   program’s curriculum development and program assessment process.

   Example #2:
   Although the program has adopted a survey instrument for its graduates, the last survey was conducted three
   years ago. Surveys should be conducted on a more systematic basis. In addition, although the survey seeks
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   feedback on the professional practices of its graduates, the survey instruments would be more effective if they
   sought feedback on graduate performance on the NCCAOM certification exam and on how well various program
   subject areas prepared them for professional practice.


 Briefly describe and assess whether equivalent methods and standards of student evaluation are applied at all
   program training sites, including externships (Criterion 7.4)

   Example #1:
   The program has made available to its interns several clinical training sites separated from the main campus.
   Clinical supervisors at these sites use the same methods and systems for intern evaluation as those used at the
   main campus clinic. The team found that training in these clinics is of high quality and that student interns are
   achieving the program’s objectives and professional competencies.

 Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliance, Area Requiring
   Further Development):


VIII. PROGRAM OF STUDY

 Briefly provide a description of the program and assess its compliance with Essential Requirement 8 (core
   curriculum) and Criterion 8.10 (Professional Competencies) Focus this review on whether students are
   achieving the required professional competencies for independent practice as required under Criterion 8.10
   and whether students are achieving program objectives and student learning outcomes .

   Example #1:
   The University offers a professional, resident program leading to the Master of Science in Acupuncture and
   Oriental Medicine that is eight semesters (for a normal FT work load) or four academic years in length. The
   Oriental medicine program is divided into a Bachelor of Science in Holistic Science and a Master of Science in
   Acupuncture and Oriental Medicine program to enable the school to offer the higher graduate program levels of
   federal financial aid for the last two years of the Masters program. Students must complete the Master’s
   program to receive the Bachelor’s degree. The curriculum meets or exceeds ACAOM’s program length
   requirements in the western sciences, herbs, theory, acupuncture and related studies, and in clinical training.
   The curriculum as a whole meets ACAOM’s core curriculum and competency requirements with the following
   exceptions.... In particular, a review of student outcome data, such as student performance on the program’s
   comprehensive graduation exam and on phase intern evaluations indicate that students are not achieving the
   required professional competencies in….. In addition, although the program explicitly lists as one of its
   educational objectives the ability of students to engage in professional AOM research, a review of student
   research projects demonstrate that students are not achieving this objective …. *describe in what respect they
   are not]

   Example #2:
   The college offers a professional, masters level certificate program in acupuncture that is twelve quarters (for a
   normal FT work load) or three academic years in length. The curriculum meets or exceeds ACAOM’s program
   length requirements in the western sciences, herbs, theory, acupuncture and related studies, and in clinical
   training. Clinical training includes 200 hours of clinical observation followed by 850 hours of internship, which
   are offered in five phases of training. The quality of didactic and clinical instruction observed by the team was,
   for the most part, high. However, the program must strengthen its practical, hands on point location and
   diagnosis training. The amount of practicum time in each practical course must be adequate and mandated. For
   example, different instructors teaching the same practical courses are inconsistent in the amount of hands on
   instruction they provide in their courses and students taking courses from one of those instructors demonstrate
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   lower pass rates for the point location and diagnosis modules of the program’s 2nd year-end comprehensive
   exam. In addition, depending on their instructors for point location, some students entering acupuncture
   techniques classes with a limited practical point location experience. In addition, a number of acupuncture
   technique classes have been too large with over 40 students, which can adversely impact the quality of hands on
   practicum training. TA’s should be considered for larger practical courses. The quality of intern patient case
   presentations also needs strengthening. Team-observed case presentations by interns were of low quality with
   inadequate levels of clinical supervisor feedback/assessment and student discussion. There were no discussions
   by students regarding the cases presented by their peers, and supervisors did not appear to adequately
   encourage or seek to foster such discussion.

 Briefly describe and assess program compliance with Criterion 8.1 a, b & c (Program Length,
   Minimum/maximum time frame, Clock to credit hour conversion)/ Criterion 8.2 (Completion Designation)/
   Criterion 8.3 (Consistent with purpose)/ and Criterion 8.4 (Level of Instruction).



   Example #1:
   The program appears to meet Commission standards governing program length, minimum and maximum time
   to completion, credit to hour conversion, completion designation, consistency with the statement of purpose,
   and appropriate level of instruction.

   Example #2:
   With the exception of the biomedical clinical sciences which are only X hours and do not meet ACAOM
   requirements, the program otherwise meets Commission program length requirements. The program also
   appears to meet Commission standards on minimum and maximum time to complete the program and
   completion designation. The program needs to revisit its clock to credit hour conversions for some courses
   listed in the catalog. As the program is on a quarter system the program’s XYZ and ABC courses do not meet the
   Commission’s requirements of 10 hours per didactic credit and 20 hours for clinic credit. The program must also
   strengthen its compliance with Criterion 8.3. In particular, the program does not sufficiently support the
   program’s educational objectives regarding the achievement of research competencies on the part of its
   students. [Explain deficiency in terms of student outcomes] The program should consider ... so that the training
   program sufficiently supports this objective. For the most part, the level of instruction is appropriate and
   rigorous. However, the site visit team noted that some biomedical faculty are not providing adequate levels of
   instruction in that.....[Explain in terms of student outcomes]

 Briefly describe and assess the adequacy of the systems implemented by the program for ensuring that off
   campus training is of sufficient quality (Criterion 8.5)

   Example #1:
   The program offers several off site clinics. Students are train at these clinics by school clinical supervisors and
   are evaluated through the same intern evaluation forms used for the main campus. The Clinic Director regularly
   visits and oversees training at off-campus clinics to ensure the quality of training at these sites. The high quality
   of training conducted at these sites was confirmed from the team visit to four of these clinics.

   Example #2:
   Although the program places some interns in the private practice clinics of participating practitioners to
   complete X hours of their internship training, the program needs to strengthen its oversight of this training. The
   team noted instances where clinical supervisors at these sites were not properly enforcing CNT/OSHA
   requirements and were not providing adequate follow-up discussions with students following patient
   treatments. In addition, many first year interns, at these sites, were observed treating patients without the

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    presence of the supervisor to correct their errors in diagnosis and point location. The Clinical Director and
    members of the school’s Academic Leadership team need to more carefully oversee training at these sites.

 Briefly describe and assess the adequacy of course syllabi relative to Criterion 8.6.

    Example #1:
    Course syllabi reviewed by the site visit team are comprehensive and complete. They all contain the purpose of
    the course, course educational objectives, prerequisites, methods of instruction, week-by-week course
    requirements, and methods of evaluation.

    Example #2:
    The program needs to strengthen syllabi for some courses. Syllabi are not in evidence for courses X, Y, Z, and
    syllabi are not consistent in format from course to course. Many were missing objectives and an adequate
    description of course material covered on a weekly basis. The Academic leadership needs to review and
    strengthen the adequacy of course syllabi.

 Briefly describe and assess the adequacy of clinical training relative to Criterion 8.7/Criterion 8.8 and Criterion
    8.9.

    Example #1:
    Clinical training consists of a clinical observation experience, which fully meets Commission standards followed
    by an internship experience where interns treat patients under the supervision of program clinical supervisors.
    Although program internship training policies fully meet ACAOM requirements for internship length and patient
    treatment numbers, actual patient volume is marginally sufficient to support the internship experience. This
    was a theme conveyed to the team by students, particularly those in the English program, as confirmed through
    the team review of the patient appointment book. A number of English students are not completing their
    studies within the program length period based on their inability to meet the patient treatment requirements.
    The program must take appropriate steps to increase the number of patients in its main campus clinic, and/or
    explore satellite clinics to ensure adequate patient populations for training. Currently interns must treat
    patients in intern teams where not all interns are performing all aspects of treatment to justify patient
    treatment credit. In addition, interns are not exposed to a sufficient variety of patients with different medical
    conditions to support quality training. These deficiencies are evidenced by student outcomes relative
    to…*Explain and document where students are not achieving required clinical competencies]

    Example #2:
    The program’s clinical training program appears to meet relevant ACAOM standards. Students begin the
    clinical experience in 200 hours of clinical observation offered in the 2nd and 3rd semesters of the program.
    Upon successful completion of clinical observation, students must pass the clinic entrance exam before
    completing the first of the five subsequent phases of clinical internship. Each phase of training leads the
    student through increasing levels of responsibility for independent patient care as clinical training progresses.
    Patient volume and variety is more than adequate to support training and interns are fully trained to administer
    all treatment modalities appropriate to an Oriental medicine program. Clinical supervisors are providing
    effective clinical instruction to program students. A review of internship evaluation forms and the team review
    of actual internship training reveal that interns are highly skilled and are achieving the clinical competencies
    expected from the program. In this regard, it is noteworthy that the program has achieved an 85% pass rate
    among its graduates on the California licensing exam, and an 89% pass rate on the national exam.

    Example #3:
    Although the program’s clinical observation experience fully meets ACAOM requirements, internship training
    needs strengthening in the following areas.... [Explain in terms of student outcomes.]

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 Briefly describe the continuing education programs of the program (if applicable) relative to Criterion 8.11.

   Example #1: The program offers continuing education programs which fully meet relevant Commission
   standards. An adequate administrative structure, a sound financial base, and appropriate facilities support
   these programs. School policy prohibits continuing education courses from being used as credit towards its
   Oriental medicine program consistent with ACAOM requirements.

 Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliance, Area Requiring
   Further Development):

   Essential Requirement 8 -- Compliance

   Criterion 8.1(a) -- Area Requiring Further Development.....

   Criterion 8.6 – Area Requiring Further Development
   Etc....

IX: FACULTY

 Briefly describe and assess the adequacy of faculty, including whether they are numerically sufficient and
   possess appropriate educational and professional backgrounds for the subject areas taught. Also describe
   whether faculty are required to keep abreast of developments within the fields in which they teach. [Focus
   discussion on the quality of instruction provided by faculty relative to student learning outcomes] (Essential
   Requirement 9/Criterion 9.1/Criterion 9.2)

   Example #1:
   Faculty as a whole are adequate and qualified to deliver the curriculum. Individual faculty members possess the
   credentials, qualifications and practical experience to provide quality instruction to program students. The
   program has a core of 27 full time faculty and 45 adjunct faculty. A number of faculty have been trained at the
   doctoral level and possess MD’s and PhD’s. Many faculty are bilingual and faculty who have been assigned to
   teach in the English, Korean and Chinese programs possess the appropriate language skills to teach in those
   languages. For the most part, faculty evaluations by the Academic Dean and team observations of actual
   instruction reveal that faculty are generally providing quality training to program students. However, a few
   faculty members do not appear to be qualified to teach the specific courses to which they have been assigned.
   For example,...[Explain]. It is important that the program’s academic leadership more carefully match faculty
   credentials to specific courses in making teaching assignments. This issue is reflected in the school’s recent
   student survey in which a significant percentage of students indicated that some faculty are not providing
   quality instruction in certain courses. The evaluation of faculty performance is somewhat inconsistent, where
   some faculty have not been evaluated by the Academic Dean for over two years. Such evaluation must be more
   systematic and consistent. Currently, evaluation of faculty appears to be conducted selectively and sporadically.

 Briefly describe and assess the conditions of faculty service and benefits, including whether there are
   adequate provisions for academic freedom and professional development relative to compliance with
   Criterion 9.3.

   Example #1:
   Faculty conditions of service at the University are better than average with adequate levels of faculty pay and
   benefits including a health and dental plan, a retirement program for full time faculty, paid holidays and
   vacation time, etc. Professional development opportunities are readily available for faculty, including program-
   sponsored faculty seminars on such topics as test construction, pedagogic techniques, course objective writing,
   and competency based learning. Faculty are eligible to attend program-sponsored CEU seminars free of charge.

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 Briefly describe and assess whether appropriate policies for faculty recruitment, appointment, promotion and
   retention have been adopted and published, including relevant provisions governing non-discrimination and
   equal opportunity. (Criterion 9.4)

   Example #1:
   The program has recently established a ranking system for faculty based on years of experience/employment,
   education, and scholarly activity, but the system has not yet been fully implemented. The policies governing
   faculty are published in a well-developed and complete Faculty Handbook. As the program has recently taken
   the position that faculty cannot teach in other area Oriental medicine schools, this decision should be reflected
   in the school’s published faculty policies and covered in faculty contracts to ensure that faculty have received
   proper notice in this regard.

   Example #2:
   Although the program has published in its Faculty Manual policies governing faculty qualifications and
   recruitment, the program needs to adopt appropriate policies on faculty promotion and retention.

 Briefly describe and assess whether the program has made adequate provisions for regular and open
   communication among faculty and between faculty and the program administration (Criterion 9.5)

   Example #1:
   Communication between the faculty and the administration is quite good with the process being facilitated
   through regular faculty meetings each quarter during which all topics of interest are discussed and through
   potluck dinners attended by students, faculty members, and the administration. The faculty feels their opinions
   are respected and that the administration is very responsive to their requests and recommendations. However,
   faculty involvement in curriculum development and program assessment needs some strengthening….*Explain
   in what respect faculty input into the process is deficient]

 Briefly list findings of the team relevant to each standard (e.g., Compliance, Non-Compliance, Area Requiring
   Further Development):

   Essential Requirement 9 – Compliance…

   Criterion 9.2 -- Area Requiring Further Development. ..
   Etc....

X. STUDENT SERVICES AND ACTIVITIES

 Briefly describe and assess whether student services and activities reflect program objectives, create good
   student morale and assist students in the achievement of personal and professional growth consistent with
   their career goals. [Focus this assessment on whether student services and activities contribute to, and
   support adequately, the achievement of mission, goals, objectives and student learning outcomes] (Essential
   Requirement 10/Criterion 10.1)

   Example #1: The program provides student services and activities that reflect the programs objectives, creates
   good student moral, and assists students in the achievement of their personal and professional objectives.
   Student services and activities fulfill the objectives of the program and meet student needs, as reflected in
   student satisfaction survey results and in the positive student learning outcomes described under Essential
   Requirements 7 & 8 of this Report . Student services include effective programs of, academic advisement,
   financial aid, student scholarships, student government, assistance in finding rental housing, computer access,
   limited health services in the school clinics, alumni association activities, etc...

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      Briefly describe and assess whether the school has published and implemented effective policies governing
      students, including a statement of student rights, privileges, responsibilities and policies governing student
      discipline. (Criterion 10.2)


      Example #1:
      The rights, privileges, and responsibilities of students and of disciplinary proceedings for violations of those
      responsibilities are made available to students through the catalog and student handbook as well as through the
      advising program at the University. The published grievance policies and procedures published by the program
      are effective, properly implemented and fully meet relevant ACAOM standards.

      Example #2:
      Although the Student Handbook contains appropriate student policies and procedures governing student rights,
      responsibilities, and conduct, the program needs to revisit its policies governing student discipline. Under those
      policies, the Academic Dean makes initial student discipline decisions, and adverse actions by the Dean can be
      appealed to the school’s Grievance Committee (comprised of the President, a faculty member, a student
      member and the Academic Dean), which renders the final decision. Having the Academic Dean consider
      appeals of disciplinary decisions of his previous decisions raises serious due process concerns. Individuals who
      render an initial disciplinary decision should not serve on an appeal panel to review that decision consistent with
      due process requirements.

 Briefly describe the provisions adopted by the program for obtaining student input into institutional decision
      making [Assess in terms of whether those provisions are effective] (Criterion 10.3)

      Example #1:
      Student input into institutional decision making is achieved through student involvement in the student
      government and through direct contact with administrators and faculty. The student government is comprised
      of class officers who are responsible for serving as liaisons between the student body and program leadership.
      Although the above systems are in place, the program needs to assess their effectiveness and how
      communication between students and the school might be strengthened. In particular, a large number of
      students sought a private interview with the team. Students asserted that a number of their concerns were not
      being adequately addressed by the program’s leadership and the student complaint files reviewed by the team
      failed to document that student complaints were effectively addressed by the program. The program needs to
      take appropriate steps to strengthen student government and properly respond to student issues and concerns
      to ensure adequate levels of communication between the program’s leadership and its students. The program
      should proactively assess the views of the student body regarding issues that impact students and the
      educational experience.

 Briefly describe and assess whether the program has adopted and properly implemented fair and efficient
      procedures for reviewing and responding to student grievances. Does the program maintain proper
      documentation of grievances and their resolution consistent with ACAOM standards? Do the grievance
      procedures disclose ACAOM contact information to program students advising them that they may contact
      the Commission if they are not satisfied with the program’s resolution of the grievance? (Criterion 10.4)

      Example #1:
      Program records of student complaints with the program’s response to those complaints are well documented
      consistent with ACAOM requirements. The school’s grievance policies advise students that they may contact
      the Commission if they are not satisfied with the program’s resolution of a grievance. Students interviewed by
      the team indicated that the program is fully responsive to their needs and concerns.


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    Example #2:
    Although the program’s policies and procedures governing grievances appear to fully meet ACAOM
    requirements, the site visit team notes that program records of student grievances are not adequately
    documented consistent with Criterion 10.4. In particular,...[Explain deficiencies in documentation] .

 Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliance, Area Requiring
    Further Development):

    Essential Requirement 10/Criterion 10.1 -- Compliance

    Criterion 10.4 – Area Requiring Further Development.....


XI. LIBRARY AND LEARNING RESOURCES

 Describe and assess the learning resources/equipment and library holdings/library and learning equipment
    access relative to compliance with Essential Requirement 11 and Criterion 11.1.

    Example #1:
    The program possesses a library at its main campus, which has sufficient space for the library collection with
    adjacent group study areas. The library possesses adequate computer stations, as well as separate space for
    large computer labs. Several separate student study areas are also provided at the campus. The library is open
    weekdays between 9:00am to 9:00pm, and Saturdays from 9:00am to 6:00pm and possesses electronic security
    measures to prevent theft. The library collection is well organized using the Dewey system. Although the library
    holdings are generally adequate in most subject areas, herb holdings are minimally adequate to support the
    school’s Oriental medicine program. In addition, journal holdings in western medicine are minimal and need
    strengthening. The program has budgeted $ XYZ annually to support the library, which is more than adequate,
    but it behooves the program to use these resources to strengthen the collection as described in this report.
    New acquisitions are currently based exclusively on requests from students and faculty. It is important that the
    program establish a well organized and systematic plan for continued library development. The program might
    wish to establish a library committee to analyze the current collection to identify holdings that will better
    support program mission, goals and objectives.

 Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliance, Area Requiring
    Further Development):

    ER 11 -- Compliance.....

    Criterion 11.1 – Area Requiring Further Development
    Etc....

    XII. PHYSICAL FACILITIES AND EQUIPMENT

 Briefly describe and assess the program facilities, including the adequacy of classroom space and equipment
  relative to Essential Requirement 12/Criterion 12.1 and whether they meet federal, state and local fire, safety
  and health standards (Criterion 12.2). Focus this review on whether facilities and equipment adequately
  support mission, goals, objectives and student learning outcomes.
  Example #1:
  The program provides exceptional leased facilities that are safe, accessible, functional, and well maintained. The
  facilities generally meet relevant local, state, and federal fire, safety, and health standards, including ADA
  requirements. The program has two campus locations, with the main campus located in Anywhere City and the
                                                                                                            Page 22 of 29
  Final Site Visit Report Template - AUGUST 2007
      other in Bogustown. The Anywhere City campus is located near a well-maintained, residential neighborhood
      and has parking for 100 vehicles. The campus is housed in a two-story building that includes 22,000 square feet
      of well-lighted classrooms, a spacious well-organized library, an accessible clinic containing administrative
      offices, many treatment rooms, a spacious patient waiting area, a complete herb pharmacy, a well-organized
      suite of offices that support the central administration, computer lab, space for program research activities, etc.
      The Bogustown campus consists of a modern two-story building with about 15,000 square feet of useable space.
      There are 20 secured underground parking spaces and an additional 30 spaces at ground level. This facility has
      eight large classrooms, a large and well equipped computer laboratory with 10 computer stations, a library with
      two individual study rooms in addition to the large open study area, a 200 seat auditorium, administrative
      offices and a 2000 square foot clinic. The clinic provides private treatment rooms, a reception area, a patient
      waiting room, and administrative offices for the clinic supervisor. Both campuses provide adequate space for
      media and learning resource equipment. The facilities are more than adequate to support the program, its
      faculty, students and staff.

      Briefly describe and assess provisions for the cleaning, repair and maintenance of facilities and grounds,
      including provisions for security, utilities and upkeep. (Criterion 12.3)

      Example #1:
      The program has adequate provisions for cleaning, repair and upkeep of the facilities and grounds, which are
      provided by the landlord pursuant to the provisions of the lease for the facility. Security of the building is
      ensured through a private security company retained by the landlord.

 Briefly describe and assess the adequacy of faculty space and learning equipment relative to Criterion 10.4.

      Example #1:
      Faculty space and learning equipment are more than adequate to support program faculty. Learning equipment
      and facilities includes projectors, LCD machines, computer equipment, copying machines, acupuncture models,
      and designated offices for administrative and faculty support.

 Briefly describe the adequacy of clinic space and equipment relative to Criterion 12.5

      Example #1:
      The school clinic is fully equipped consistent with ACAOM requirements and is adequate for the program’s
      clinical training needs.

 Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliance, Area Requiring
      Further Development):

      ER 12 -- Compliance....

      Etc....


XIII. FINANCIAL RESOURCES

     Briefly describe and assess the adequacy of financial management, controls, and budgeting systems and
      assess whether the program is financially stable and is expending sufficient financial resources to meet
      program needs (Essential Requirement 13/Criterion 13.1/Criterion 13.2/Criterion 13.3/Criterion 13.4 Criterion
      13.5 & Criterion 13.6).


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    Final Site Visit Report Template - AUGUST 2007
   Example #1:
   Financial stability is a substantial strength of the institution. The program is financially sound and has resources
   sufficient to carry out its objectives and to support the program for the foreseeable future. Financial
   management systems, including day-to-day bookkeeping, are strong and appropriate. The CPA prepares audited
   financial statements annually. The institution has for many years demonstrated its commitment to sound
   financial practices as demonstrated by their financial statements. Z-scores for the past several years have been
   well within the financially stable range with substantial year end surpluses in the hundreds of thousands of
   dollars. This pattern of consistent improvements in financial resources has permitted the Board of Trustees to
   continue its program of improving the facilities and resources in support of the academic program. The
   budgeting process is generally strong and the Board of Trustees, President, Chief Financial Officer and the CPA
   are closely involved in overseeing the institution’s financial status. The Treasurer prepares budgets with the
   assistance of the CFO, Financial Aid Officer, with input from senior administrative staff. Budgets are reviewed
   and approved by the Board of Trustees. The program, for the most part, has been operating within its approved
   budgets. However, tying projected budgets to a clear, well developed strategic plan could strengthen the
   budgeting process. Such a plan will be critical to the future budgeting process given the institution’s aggressive
   and ambitious plans for expansion and growth, including the offering of a doctoral program, consideration of
   regional accreditation, and plans for establishing new branch campuses.

 Briefly describe and assess whether the program has adequate financial resources to meet debt service
   requirements without adversely impacting program quality (Criterion 13.7)

   Example #1:
   The program’s is having difficulty in paying off a $200,000 bank loan as evidenced by the many late payment
   notices from the school’s creditor. The program’s ongoing challenge in meeting its debt service requirements
   has resulted in the school’s inability to adequately support the program consistent with ACAOM requirements
   [Explain in what respect financial resource deficiencies have adversely impacted the program or compliance
   with ACAOM standards]

 Briefly describe and assess the financial aid operations of the program, whether it is capably administered and
   whether cohort default rates are at a reasonable level (Criterion 13.8/Criterion 13.9)

   Example #1:
   The financial aid program is capably administered and the recently reported cohort default rates have been at
   3% or less. The credit for this improvement has been the improvement in the due diligence shown by the
   financial aid director and the counseling the students have been receiving.

   Example #2:
   The College’s financial aid operations constitute a serious challenge for the institution. The site visit team noted
   several concerns in this regard. There has not been a consistent system of properly implementing all USDE Title
   IV financial aid regulations and implementing proper campus policies consistent with those requirements.
   Several school policies and their implementation violate USDE requirements and in some cases are inconsistent
   from publication to publication. For example, one version of the school’s policies on student refunds for
   withdrawn students uses a pro-rata refund calculation with no refunds due after students withdraw after
   completing 45% of the program (which violates USDE requirements) and another version uses a 60% cut off
   which does meet USDE requirements. Similarly, the school’s satisfactory academic progress policy fails to tie
   compliance with this policy to continued eligibility for Title IV financial aid. Evidence of consistently
   implementing requirements for exit interviews of students is lacking. For example, when the college is unable to
   conduct an exit interview, there is no evidence of written follow-up with students documenting that they
   received appropriate information that would be covered in a properly implemented exit interview. Evidence of
   USDE refund calculations for withdrawn students prior to 60% completion of the program is entirely lacking and
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           this would be considered a material non-compliance by the USDE. The process of verification of selected
           students is also inconsistently administered and completed. Verifications must be clearly documented within
           student financial aid files and in communications with the USDE. Cohort default rates are inordinately high at
           25% for the most recent USDE audit.

      Briefly describe the refund policies of the program relative to compliance with Criterion 13.10

           Example #1:
           The program’s publications clearly define a fair and equitable refund policy and follow the applicable state and
           federal laws and regulations.

          Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliance, Area
           Requiring Further Development ):

           ER 13 -- Non-Compliance.....

           Criterion 13.8 – Area Requiring Further Development....
           Etc....

XIV. PUBLICATIONS AND ADVERTISING

      Briefly describe whether the school catalog and other publications meet the requirements of Essential
           Requirement 14.

     Example #1:
     In general, publications of the institution are a strength. The catalog, and all manuals, handbooks and other
     publications are clear, well written and transparent to the reader. The catalog contains all the required elements
     under ER 14, and fully meets ACAOM standards. The Policies and Procedures Manual is well organized and
     provides clear direction to all program constituencies as to the school’s policies, procedures and practices.
     Although the web site contains many of the school’s policies and procedures in all three languages, key school
     publications such as the catalog and manuals and handbooks made available to students should be available in
     Chinese and Korean to ensure that non-English program students have full access to critical school policies and
     procedures impacting students.

           Briefly describe and assess whether school publications, advertising and other communications concerning
           the school and its programs, services, activities, etc are accurate and unambiguous (Criterion 14.1/Criterion
           14.2/Criterion 14.3).

           Example #1:
           School publications, advertising were found to be clearly written and accurately reflect the program and its
           policies, procedures and practices. There is no evidence that the program has misrepresented employment,
           career or licensure opportunities.

           Example #2:
           Although the catalog is generally accurate, except as noted below, the program must ensure that its
           advertisements accurately reflect the program. In this regard, the following deficiencies are noted...[Describe
           deficiencies]. In addition, the program must ensure that the policies published in the Student and Faculty
           Handbooks are consistent with the policies published in the catalog. For example, the catalog versions of the
           program’s admissions and satisfactory academic progress policies are different from those contained in the
           Faculty and Student Manuals. The catalog also needs to delete the reference to its Herbal Certificate program,

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         Final Site Visit Report Template - AUGUST 2007
         which has not been offered for two years. There is no evidence that the program has misrepresented
         employment, career or licensure opportunities.

       Briefly describe whether the program has reported accurately its status with ACAOM consistent with Criterion
         14.4.

      Example #1: The program’s published statement of its accredited status with ACAOM is consistent with ACAOM
      requirements.

       Briefly list findings of the team for each relevant standard (e.g., Compliance, Non-Compliance, Area Requiring
         Further Development):

XV.   SUMMARY OF TEAM FINDINGS

         This section of the report lists all findings of the site visit team categorized by the type of finding (i.e.,
         Compliance, Non-Compliance, Area Requiring Further Development)

         Areas of Compliance
         List all Essential Requirements in which the program is in compliance.

         Examples:

         1. Essential Requirement 2 – The program meets all relevant laws and regulations applicable to its operations.
         2. Essential Requirement 4 – The institution has a qualified Chief Administrator and a qualified administrative
              staff sufficient to meet the needs of the program.
         3.....
         4.....
         Etc......

         Areas of Non-Compliance

         List all areas of non-compliance identified by the site visit team in this section of the report

         Criterion 1.4 -- Non-Compliance:.....

         ER 2 – Non-Compliance:........

         Etc.....

         Areas Requiring Further Development

         List all areas requiring further development identified by the site visit team in this section of the report

         Example:

         Criterion 4.3 – Area Requiring Further Development: ........

         Essential Requirement 6 – Requiring Further Development: ........

         Etc….

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       Final Site Visit Report Template - AUGUST 2007
  Respectfully Submitted,

  [List team members here]




                                                 Page 27 of 29
Final Site Visit Report Template - AUGUST 2007
                                        ACCREDITATION COMMISSION
                                  FOR ACUPUNCTURE AND ORIENTAL MEDICINE


                     TEMPLATE – SITE VISIT TEAM RECOMMENDATION TO THE COMMISSION

Example for a Candidacy Site Visit Review:

(The site visit team’s formal recommendation to the Commission regarding a candidacy decision is provided to the
Commission only and is not a part of the site visit report that is sent to the program.)


                                       CONFIDENTIAL TO THE COMMISSION

                                       SITE VISIT TEAM RECOMMENDATION


The site visit team recommends that Candidacy status be given to the professional Oriental medicine diploma
program of the ABC College of Oriental medicine based on its findings that:


   1. The program is substantially in compliance with the Commission’s fourteen (14) Essential Requirements and
      may reasonably be expected to meet the Criteria for Accreditation.

   2. The program is capable of undertaking and completing the self-study process required for accreditation
      within three years of achieving Candidacy status.

   3. The program is accomplishing its stated objectives.


It is recommended that the Commission specify a period of time in which the area of non-compliance is to be
remedied in order for Candidacy status to be maintained and that the program be required to submit an interim
report demonstrating substantial strengthening of these areas to be followed by a focused site visit to confirm
compliance with the accreditation criteria.


Respectfully Submitted,


LIST TEAM MEMBERS HERE




                                                                                                      Page 28 of 29

   FINAL SITE VISIT REPORT TEMPLATE - AUGUST 2007
                                         ACCREDITATION COMMISSION
                                   FOR ACUPUNCTURE AND ORIENTAL MEDICINE


                     TEMPLATE – SITE VISIT TEAM RECOMMENDATION TO THE COMMISSION

Example for a Accreditation Site Visit Review:

(The site visit team’s formal recommendation to the Commission regarding an accreditation decision is provided to
the Commission only and is not a part of the site visit report that is sent to the program.)



                                        CONFIDENTIAL TO THE COMMISSION

                                        SITE VISIT TEAM RECOMMENDATION


The team recommends that the Commission continue the accreditation of [grant initial accreditation to] the XYZ
College of Oriental Medicine.

   1. The team’s reasons for its recommendations are as follows:

   2. The team finds that the program is substantially in compliance with the fourteen (14) Essential
      Requirements.

   3. The vast majority of program deficiencies can be easily corrected within a short period of time.

   4. The program has made substantial progress in strengthening its compliance with the accreditation standards
      since the last Commission review.

   5. The program has an organization, purpose and resources sufficient to carry out its purpose and has
      demonstrated its ability and willingness to make the changes necessary to come into full compliance with
      the criteria.


Respectfully Submitted,

LIST TEAM MEMBERS HERE




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 Final Site Visit Report Template - AUGUST 2007

				
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