East Carolina University
Department of Recreation and Leisure Studies
AGENCY APPLICATION
FOR THE PLACEMENT OF RECREATIONAL THERAPY (RT) INTERNS
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FOR OFFICE USE ONLY
Date received:
RT Degree Internship Coordinator Approval Date:
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Instructions: Please click on the gray box and type your responses to each question (the space will expand as needed).
Please provide supporting documentation whenever possible. If written information about the Agency and RT
Department exists, please attach those materials to this form. Participation as an internship agency is a significant professional commitment, which is very much appreciated.
Student name(s) applying for internship (if known) :
Agency Name:
City: Street:
Website URL:
Contact Person:
E-mail:
Department name:
Phone (area code)
State:
:
Zip:
Eligibility Criteria: The RT program requires a one-to-one ratio (CTRS supervisor to intern) for first time ECU RT program-affiliated agencies and a one-to-two maximum ratio (CTRS supervisor to intern) for those sites with which the RT program has an established affiliation. This means that for a newly affiliated agency if there is only one CTRS on staff the agency may accept only the one ECU intern. If the agency is established with the
ECU RT program, one CTRS may supervise up to two interns (e.g., two interns from ECU, or one ECU intern and one intern from another institution). Can you, and are you willing to, meet this supervisor/student ratio?
YES NO
It is important for interns to have opportunities to ask questions and receive feedback from their supervisor on a regular basis. Do you agree to provide onsite supervision and meet weekly with the intern to provide feedback? YES NO
AGENCY INFORMATION
How long has the agency provided recreational therapy services? YEARS MONTHS
Please check any specific requirements/policies interns must meet before placement.
Blood-borne pathogens certification
TB screening
Health insurance
Criminal background check
Drug screening
Valid driver’s license
Liability insurance
Other (specify) :
(which level?)
1

What is the mission of the agency? Provide additional documentation or attachments if appropriate.
What is the mission of the Recreational Therapy Department/Program?
Check all that relate to the types of services/settings you provide:
Physical rehabilitation Substance abuse rehabilitation
Psychiatric Rehabilitation
Major illness rehabilitation
Developmental disability services
Skilled nursing/Extended care services*
Educational setting
Day treatment
Corrections/Juvenile detention*
Community based services
OTHER (specify)
* For RT programs in skilled nursing/extended care and corrections settings, is the CTRS using the MDS Section
3.0 Resident Assessment Instrument (RAI)? YES NO
The MDS-RAI is a tool to collect individualized information about each resident using established medical codes.
The primary purpose of the RAI is to provide a basis to develop an individualized person-centered care plan for a resident. The assessment instrument consists of 3 basic components: (1) the MDS 3.0, (2) the care area assessment process, and (3) utilization guidelines. The RAI must be completed for every person residing in a
Medicare and or Medicaid certified facility. Its use is mandated in assessing people who receive post acute, short term, and long-term care through CMS certified care facilities. MDS RAI manuals and information are posted on the CMS website .
What are the primary age groups served by the RT program? Check all that apply
Senior adult (65+ years) Adolescents (13 – 18 years)
Mid-adult (30 – 64 years) Youth (5 – 12 years)
Young adult (18 – 29 years)
TRA
OTHER (specify)
Pre-school (< 5 years)
Identify the number of staff allocated to provide recreational therapy services at the agency.
CTRS Licensed as RT
(in applicable states)
Non-certified personnel
Please explain the role of recreational therapy within the service delivery structure of the agency (attach documentation as appropriate) .

NCTRC JOB ANALYSIS TASK DOMAINS
According to the NCTRC, an acceptable field placement experience is defined by the therapeutic recreation process as delineated in the NCTRC Job Analysis Study Task Areas. The NCTRC Job Analysis Task Domains are:
Professionals roles and responsibilities
Assessment
Documenting intervention services
Working with treatment and/or service teams
Planning interventions and/or programs
Implementing interventions and/or programs
Evaluate intervention/program outcomes
Organizing programs
Managing TR/RT services
Public awareness and advocacy
Are the NCTRC Job Analysis Task Domains evident and active at this agency? YES NO
At your agency are orders for Recreational Therapy written by a physician? YES NO
CTRS ACTIVITIES
Instructions: Please indicate the frequency of each activity conducted by the CTRSs at your agency:
Other
Other
Other
(specify)
(specify)
(specify)
Professional Practice
Consumer/client assessment
Client treatment/care/developmental planning
Documentation and progress charting
Discharge planning
Program/outcome evaluation
:
:
:
Daily Weekly
Biweekly
Monthly N/A
INTERNSHIP SUPERVISORS
Instructions: Please list the names of agency personnel who will serve as internship supervisor(s). For each individual listed, please attach a copy of her/his credentials (national and state, as applicable). NOTE: ECU requires the internship supervisor’s credentials to be current throughout the length of internship. If the supervisor’s credentials will expire during the internship period, please submit the name and credentials of a secondary supervisor, whose credentials are valid throughout the internship.
SUPERVISOR CTRS 1:
Name: Email:
Phone
(area code)
: NCTRC number: State license (as applicable) :
SUPERVISOR CTRS 2:
Name:
Phone
(area code)
:
Email:
NCTRC number: State license (as applicable) :

SUPERVISOR CTRS 3:
Name:
Phone
(area code)
:
COMMENTS/ADDITIONAL INFORMATION:
Email:
NCTRC number: State license (as applicable) :
QUESTIONS?
Please contact:
Ms. Rebecca Riedl, RT Internship Coordinator
Office: (252) 737-2280 riedlr@ecu.edu
When completed, please scan or upload your materials as attachments and EMAIL to: riedlr@ecu.edu
Alternatively, you may FAX the documents to
Ms. Rebecca Riedl, RT Internship Coordinator at 252-328-4642
Or, you may send the packet BY POST to:
Recreational Therapy Internship Coordinator
The Department of Recreation and Leisure Studies
1410 Carol Belk Building; Mailstop 540
Greenville, NC 27858-4353