PRSS Internship Site Interest Survey Question Title * 1. Please complete the information for the agency interested in hosting a PRSS intern. Agency Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 2. Please complete this information for the agency internship contact.This would be the individual that will receive primary communication from Governors State University with regards to internship placements, intern expectations and intern supervision. Name Company Email Address Phone Number Question Title * 3. Please complete this information for the agency legal contact. This would be the individual at your agency that is able to legally sign contracts and agreements on behalf of the agency. This individual may be located at a different location then the internship contact. Name Job Title Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 4. What are your agency's hour of operation? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Question Title * 5. If your agency has multiple physical locations that could host a PRSS intern please list the location names and cities in which they are located. Question Title * 6. Please check all that are required for an intern to have to work at your organization: Background Check Current TB Test COVID-19 Vaccination Malpractice Insurance Other (please specify) Question Title * 7. Does your agency require that an intern be currently in personnel recovery? If yes, please include the length of time No Yes (please specify minimum length) Question Title * 8. How far in advance do you need to know about an internship placement? 1 week or less 1-4 weeks 1-3 months 3-6 months Some other length of time (please specify) Question Title * 9. Can you briefly describe any application process the intern will need to complete at your agency in order to be eligible? Question Title * 10. Briefly explain what roles a Peer Recovery Support Specialist Intern would engage in at your agency? Question Title * 11. Please mark any populations your agency specializes in working with?We understand you may serve all of these populations but only select group if they are a target group for your agency or your agency has requirements regarding an individual identifying as one of the following in order to receive treatment. Individuals with Substance Abuse Disorders Individuals with Mental Health Disorders Individuals with Behavioral Health Disorders Veterans Youth or Adolescents Women Men LGBTQIA+ Done