UW-L Therapeutic Recreation Internship Site Questionnaire by wanghonghx


									                      UW-L Therapeutic Recreation Internship Site Questionnaire
                                                          For Agency Approval
               Department of Recreation Management and Therapeutic Recreation
                                                             128 Wittich Hall
                                         University of Wisconsin - La Crosse
                                                La Crosse, Wisconsin 54601
                                                  Telephone: (608) 785-8199
                                                         FAX: (608) 785-8206
              Contact: Susan "BOON" Murray, Ed.D., CTRS, Internship Coordinator
This questionnaire will provide information to faculty and students relative to your agency, department
and/or unit. Please answer all the items and feel free to provide additional information that you think
important. In an effort to provide one comprehensive questionnaire for all agencies that seek to
become an approved site, information requested may not appear applicable to your agency. If this is
the case, please indicate "NOT APPLICABLE" for that specific question.

The questionnaire is divided into six sections.
Section I:   General Application Information
Section II:  Agency Information
Section III: Department or Unit Information
Section IV: Agency Prerequisites
Section V: Supplementary Information: Student Concerns
Section VI: Certified Staff Information

Faculty will evaluate your completed questionnaire in approving sites. A copy of your questionnaire
will be placed in a separate notebook customized for each agency for students seeking internships.
Therefore, please enclose the following:
     your business card or your internship coordinator's business card,
     agency and departmental brochures,
     application materials for interns, and
     a sixteen-week schedule that shows how the intern will be mentored into the job competences
        of a therapeutic recreation specialist as defined by NCTRC.
When returning this form, please attach copies of any current CTRS certifications of prospective
internship supervisors or staff.


Application Date:
Name of Agency:

                (City)                       (State)                      (Zip)

Name of Administrative Officer:
Telephone Number:
                         (Area Code & extension)

Name of Director or Supervisor (contact person) of Therapeutic Recreation Services:
Telephone Number:
                         (Area Code & extension)

FAX:                E-Mail
World Wide Web address (URL):
Name of Person Completing the Questionnaire:
The maximum number of Therapeutic Recreation students, which our agency can supervise during each
semester, is ( ). No more than one intern student can be in a specific program at any given time.

Effective Summer 2001, summer internships will also be 16 weeks long (40 hours a week). There may be an
overlap of students between summer and fall internships for about two weeks during the 3rd and 4th weeks of
the August. Please check  whether your agency is or is not willing to take internship students during
   will take summer interns    will not take summer interns

1.       What client populations do you serve, at what age of development, and approximately how many are
         served in each group? (Circle the number corresponding to client group(s) and fill in the number of
         clients in the blank next to the identified group.) Use the last 12 months of operation to obtain
         approximate numbers.

                     # of                          AGE GROUP
DIAGNOSTIC GROUPS Clients         Children   Adolescents Adults           Older Adults

Mentally Ill                          1                2           3              4
Moderately Mentally
 Retarded                             1                2           3              4

Severely Mentally
 Retarded                           1             2              3             4
Visually Impaired                   1             2              3             4
Hearing Impaired                    1             2              3              4
Physically Disabled                 1             2              3              4
Aging/Geriatric                     1             2              3              4
Pediatric                           1             2              3              4
Chemically Dependent                1             2              3              4
Legal Offenders                     1             2              3              4
General Medical                     1             2              3              4
Multiply Handicapped
 (specify)                          1             2              3              4
Learning Disabled                   1             2              3              4
Behavior Disorders                  1             2              3              4
Other (specify)                     1             2              3              4

2.     In general, how can your agency be classified? (Check all that apply.)
           Treatment/Rehabilitation hospital based
           Treatment/Rehabilitation non-hospital based
           Long term health care
           Day treatment
            Community-based recreation
                  a. Special recreation association
                  b. Not-for-profit community based
                  c. Division or unit within community parks and recreation department
           Other (specify)

3.     Is your agency accredited by any of the following organizations?
           Joint Commission on Accreditation of Health Care Organizations (JCAHO)
           Commission on Accreditation of Rehabilitation Facilities (CARF)
           Accreditation Council for Developmentally Disabled Persons (AC-DD)
           Other (please specify)

4.     If your agency is accredited by the Joint Commission on Accreditation of Health Care Organizations,
       which of the following standards are employed?
           JCAHO Hospital Standards
           JCAHO Ambulatory Care
           JCAHO Consolidated Standards
           JCAHO Long Term Care
           JCAHO Hospice
           Other (please specify)

5.        To what extent is the therapeutic recreation program incorporated into the agency's accreditation

                      1                     2                   3                    4               5
                    not at all                                                                     extensively

6.        In which of the following programmatic documentation procedures is your TR Department involved?
          (Check all that apply):
             Agency Quality Improvement Plan
             Evaluation and monitoring review at department level (QA)
             Agency Evaluation Plan
             Utilization Review
             Other (please specify)

7.        Briefly state your agency's purpose or mission.


1.        State the philosophy (i.e., purpose) of your therapeutic recreation department or unit.

2.        List the major goal areas addressed by your therapeutic recreation department or unit.

3.        What programs, if any, do you offer under each of the following categories? Use additional page(s) if
          necessary. Include the approximate percentage of your total program hours that are devoted to each of
          these categories.

          Rehabilitation/Therapy (Improvement of functional behavior).........                           percent

          Leisure education.............................................................                 percent

          Recreation participation.....................................................                  percent

          Combination programs.....................................................                      percent

4.        What type of "written plan of operation" does your therapeutic recreation program use?
            None used
            Thoroughly documented comprehensive plan including documentation of TR programs
            Policy and procedure manual
            Other (please explain)

5.        Please indicate the extent to which your TR staff are involved in the following procedures.
                                                   Not at all          Sometimes           Often          #hours/week

     Direct client service                            1                    2                 3
     Client assessment                                1                    2                 3
     Treatment/program plans                          1                    2                 3
     Progress notes                       1               2               3
     Treatment/program plan
     reviews (staffing)                   1               2               3
     Discharge planning                   1               2               3
     Quality Assurance
     monitoring and evaluation            1               2               3
     Staff growth and development         1               2               3
     Program evaluation                   1               2               3
     Peer reviews                         1               2               3
     Supervision of interns               1               2               3
     Other                                1               2               3

6.        Please indicate the extent to which each of the following are documented (written):

                                          Not at all             Some           Thoroughly
     TR program philosophy                       1                        2            3
     TR program goals                            1                        2            3
     TR program objectives                       1                        2            3
     Policies and procedures                     1                        2            3
     Participant involvement                     1                        2            3
          a. attendance records                  1                        2            3
          b. individual client goal(s)           1                        2            3
          c. progress towards goal(s)            1                        2            3
          d. other (specify)                     1                        2            3
     Recommended program content                 1                        2            3
     Recommended Leadership process              1                        2            3
     Quality assurance monitoring/evaluation     1                        2            3
     Staff growth and development                1                        2            3
     Program evaluation                          1                        2            3
     Peer review process                         1                        2            3
     Clinical privileging                        1                        2            3

7.        Which of the following procedures are used for client placement in the therapeutic recreation program?
                                               Rehab.         Leisure         Recreation
                                               Therapy        Education       Participation
     Clients are referred by physician           Y    N         Y    N          Y     N
     Clients are referred by primary therapist   Y    N         Y    N          Y     N
     Clients are recruited by TR staff           Y    N         Y    N          Y     N
     Clients decide to participate               Y    N         Y    N          Y     N
     Clients are placed into program based
      on individual client assessment            Y    N         Y     N         Y     N
     All clients are expected to participate     Y    N         Y     N         Y     N
     All clients who are able to are
       expected to participate                       Y     N        Y   N        Y      N
     Other (please specify)

8.        How are clients placed into programs? (Please prioritize; 1 = first factor, 2 = second factor etc.)
                Assessment procedures
                Activity selected
                Age group
                Disability category
                Ability level
                Other factors (please specify)

9.        Does your agency have any system for communicating with other area agencies and obtaining referrals
          from them (i.e., post-discharge, follow-up)? Please explain.

10.       To what extent is therapeutic recreation included in the process and documentation of the client's
          treatment plan? (check all that apply)
             TR staff attend inter/multi-disciplinary team treatment/program meetings.
             TR is not included in the client's treatment/program plan
             TR is involved in the treatment/program plan and this involvement is not documented in the client's
                 main chart
             TR is involved in the treatment/program plan and this involvement is documented in the client's main
11.       When TR is included (documented) in a client's treatment/program plan, which of the following items
          are documented?
             client problem, goal or objective unique to TR services
             client problem, goal or objective relevant to TR but not unique to TR
             estimated time frames to achieve specific goals
             updates of treatment plan
             other (please specify)

12.       Does TR have a separate treatment/program plan for each client?
            never                sometimes            usually                     always

13.       Briefly describe your treatment/program planning process.

14.       How often is the input into a client's treatment/program plan based upon the results of an assessment?
            never                    sometimes              usually             always

15.       Describe client assessment procedure. (Please attach a copy if an instrument is used.)

16.       Briefly describe your charting and record keeping procedures.

17.       Briefly describe your discharge planning/referral procedures.

18.       List and briefly describe your physical facilities.

19.       Briefly describe how your agency receives payment for the services of the
20.   Identify currently practiced facilitation techniques (i.e., behavior modification, counseling approaches)

21.   Does your agency follow the NTRS Internship Standards and Guidelines for Therapeutic Recreation?
      (National Therapeutic Recreation Society, 1997, ISBN 0-929581-59-8) (available for purchase from
      National Therapeutic Recreation Society (NTRS), National Recreation and Park Association, 22377
      Belmont Ridge Road, Ashburn, VA 20148-450 Phone (703) 858-0784, Fax (703) 858-0794;
      Yes                   No

      To what extent?

      How is this document utilized?

22.   Does your agency adhere to either or both the NTRS Standards of Practice for Therapeutic Recreation
      (see purchase information above) and/or the ATRA Standards for the Practice of Therapeutic
      Recreation? (available for purchase from the American Therapeutic Recreation Association (ATRA),
      1414 Prince Street, Suite 204, Alexandria, Virginia 22314 (703) 683-9420 telephone, (703) 683-9431
      fax. (www.atra-tr.org)

      Yes            No

      NTRS                   ATRA                   Both

      To what extent?

      How are these documents utilized?

23.   Does your agency adhere to NTRS Guidelines for Administration of Therapeutic Recreation Service
      (revised 1997)? (see purchase information above)

      Yes            No

      To what extent?

      How is this document utilized?

24.   Does your agency adhere to NTRS and APRS Guidelines for Community-Based Recreation Programs
      for Special Populations? (see purchase information above)

      Yes            No

      To What extent?

      How is this document utilized?

25.   Which journals are readily available to Therapeutic Recreation staff and Internship students?

26.   Do Therapeutic Recreation staff participate in any professional organizations?

                                                              Member          On Committee

American Therapeutic Recreation Association (ATRA)              yes      no        yes      no

National Therapeutic Recreation Society (NTRS)                  yes      no        yes      no

State Therapeutic Recreation Society                            yes      no        yes      no

Local Therapeutic Recreation Organization                       yes      no        yes      no

Child Life Council                                              yes      no        yes      no

Other (Please indicate)


The following information will assist the students in securing a site compatible with their interest and needs,
and will inform students of what your agency prerequisites are prior to the student beginning their internship

1.     Special skill: Please list minimal special skills necessary to do the Internship experience at your
       agency. List what type(s) of skills students should have before they report to your agency. (Please be
       brief as the computer program has only three lines set aside for this section).

2.     Special knowledge: Please list minimal special knowledge necessary for students to have prior to
       reporting to your agency. (Please be brief as the computer program has only three lines set aside for
       this section).

3.     Recommended courses: Please list any courses you feel students should have in addition to the
       required Therapeutic Recreation course curriculum. A University of Wisconsin-La Crosse catalog will be
       forwarded to you for your convenience.


1.     What is the student internship application procedure for your agency?

2.     Is there any financial support for students during internship? (Note: Financial support is not required or
       even desirable within the University of Wisconsin-La Crosse internship program. It should be further
       noted that if a student receives any financial reimbursement or stipend from the agency, training hours
       and working hours (compensated time) will need to be identified before the student begins their
       internship. Furthermore, the university liability insurance will be in effect during training hours only. This
       question is included for general information and when financial assistance is needed for a given
                     no financial support
                     salary                   amount
                     hourly wage              amount
                 stipend                     amount


3.     Can you assist in locating housing for internship students?

          Yes              No

  If yes, what type? For how much?           Free of charge                    Rental

       University or Facility Dormitory                              or    $

       Rooms                                                         or    $

       Apartments                                                    or    $


4. Are any other services or benefits available? (Check all that apply.)
      food plan
      medical care
      liability insurance
      other (specify)



The National Council on Therapeutic Recreation Certification (NCTRC) Field Placement Requirements states:

"A professional level field placement experience completed after January 1, 1986 must be under an
agency field placement supervisor who is certified by NCTRC at the Therapeutic Recreation
Specialist-Professional level."

Please list below the requested information on all full-time agency paid therapeutic recreation staff
personnel. Please list part-time agency paid therapeutic recreation staff personnel on the next page.

Name of Full-time               NCTRC
Staff Member                    Certification #                 Expiration Date______________


List of Part-time agency paid Therapeutic Recreation personnel.

Name of Part- time               NCTRC
Staff Member                     Certification #                  Expiration Date___


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