SURVEY OF NORTH CENTRAL REGION CENTERS

Designed to help us understand what are "common practices" region wide and to determine how much variance there is.


Center or System:                           

Component Site or Satellite:          

Person completing the survey:     
                                                                                                       

1.  Fee Structures - tuition charge per unit offered

    Clinical done in-house Clinical done elsewhere  
     Entry Format:  $0000.00 Entry Format:  $0000.00  
Summer Unit Intensive        
Fall Unit Intensive        
Winter Unit Intensive        
Spring Unit Intensive        
Extended Unit        
Residency - 1st unit        
Residency - subsequent units        
Supervisory Education - 1st unit        
Supervisory Education - subsequent units        
Tuition reduction for subsequent units for continuing students        


2.  Application, Interview & Deposit Fees

        Amount  
    Yes No Entry Format:  $0000.00  
Application Fee to your Center        
Interview Fee for admission to your Center          
Is the Interview Fee waived or deducted from tuition if accepted to your program?          
Interview Fee for application to other Centers          
Deposit to hold place in program - single unit          
Deposit to hold place in residency          
Deposit to hold place in supervisory education slot          
Is the deposit to hold place refundable?          


3.  Residency / Supervisory Education Program Structure

        Amount per annum in $   
Entry Format:   00000.00  		 
    Yes No Amount per annum in days --  Entry Format:   00  
        Date
Entry Format:  mm/dd		  
9 month - 3 unit residency        
12 month - 3 unit residency          
12 month - 4 unit residency          
     Residency Stipend for above?                 $  
     Residency Health Benefits for above?     
     Do Residents pay for these benefits?        In part:
      Holidays / Vacation Days / PTO  for above?         days
2nd Year residency?          
     Residency Stipend for second year?                 $  
     Residency health Benefits for second year?       
     Do 2nd year residents pay for these benefits?        in part:
   Holidays / Vacation Days / PTO for second year?           days  
Do you admit quarter students into the residency group?        
What is the start date of your residency year?          date  
What is the end date of your residency year?          date   
Supervisory education?        
     Supervisory Education Student Stipend?                $  
     Supervisory Education Student health Benefits?         
    Do SES pay for these benefits?        in part:
     SES Holidays / Vacation Days / PTO?           days  


4.  Additional Questions

  Yes No Date or Amount  
Do you have a target cut off date for applications for summer CPE?           mm/dd  
Do you require a unit of CPE for admission into your residency program?        
Do you require on call for single unit students?        
     How many hours, days or nights per week?         
Examples: 8 hours; 1day; 2 nights		  
Do you require on call for residents?        
     How many hours, days or nights per week?        
 Examples: 8 hours; 1day; 2 nights		  
How do on call hours compute toward the total clinical hours required for a unit?        
Provide narrative explanation