Affiliation Agreement Form

Affiliation Agreement Update Request Form

This addendum is to update the current Affiliation Agreement for your currently existing contract or agreement with ACC Health Sciences.

Date of Request

Section 1: Requestor Information

Full Name

Title / Role

Email Address

Phone Number

Department

Section 2: Existing Agreement

Name of Clinical Site Facility

Is this an existing active agreement?

Clinical site Point of Contact (POC) Name
(if known)

Clinical Site POC Email
(if known)

Clinical Site POC Phone
(if known)

Section 3: Request Details & Timeline

Type of Addendum (og)

Type of Addendum

Please specify

Reason for addendum request

Please specify

Please provide a detailed description of the changes being requested.

Proposed Effective Date of Addendum

Is this request time sensitive?

YesNo

If yes, explain deadline and impact if delayed
(e.g. students cannot be placed without agreement update)

Section 4: Program Information

Program Name

Credential Type