Externship Program Site Information

Please fill out the following information for the Oklahoma State University, Department of Veterinary Clinical Sciences

Site/Practice Name
Site/Practice Address Site/Practice Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Site/Practice Phone Number Site/Practice Phone Number - ### - ### ####
Site/Practice Fax Number
Site/Practice Email Address
Site/Practice Website Address
DVM Name (s)
Primary Contact Information
Name Name First Last
Title
Phone Phone - ### - ### ####
Email
Site Description

Site Description Avian/Exotics Exlusive Equine Exclusive Food Animal Exlusive Large Animal (Equine & Food Animal) Exlusive Small Animal Lab Animal Mixed Practice
How many board certified specialists in practice?

Insert number of specialists in each category.
ACVIM
ACVS
ABVP
ACVO
ACVR

Indicate whether the site/pracitce has or offers these services, facilities, or equipment
	Yes	No
Surgical Facilities	Surgical FacilitiesYes	Surgical FacilitiesNo
Endoscopic Equipment	Endoscopic EquipmentYes	Endoscopic EquipmentNo
Radiographic Equipment	Radiographic EquipmentYes	Radiographic EquipmentNo
Ultrasound Unit	Ultrasound UnitYes	Ultrasound UnitNo
After-hours emergency services	After-hours emergency servicesYes	After-hours emergency servicesNo
Hospitalize patients overnight	Hospitalize patients overnightYes	Hospitalize patients overnightNo
Ambulator service	Ambulator serviceYes	Ambulator serviceNo

Approximate Number of Cases per YEAR at this site.

Enter the approximate number for each species
Bovine
Canine
Equine
Feline
Lab Animal
Porcine
Small Ruminants
Zoo/Exotics/Wildlife
Others, specify
Does this practice have an internship/residency program?

Does this practice have an internship/residency program? Yes No
If yes, does this practice participate in the VIRMP Matching Program?

If yes, does this practice participate in the VIRMP Matching Program? Yes No
Approximate number of employees at this location

Enter the number of employees per category.
Veterinarians
Veterinary Assistants
Veterinary Technicians – Licensed
Veterinary Technicians – Non-licensed
Kennel/ Barn Staff
Business/ Practice Manager
Office Staff
Do you offer any stipends?

Do you offer any stipends? Yes No
Is housing provided?

Is housing provided? Yes No
Other, please specify:
Will a vehicle be necessary?

Will a vehicle be necessary? Yes No
Types of experiences/ cases seen at your clinic:

Types of experiences/ cases seen at your clinic: Hands-on Hands-off
Comments