Fillable AFFILIATION AGREEMENT COVER SHEET / Checklist Please complete (Pennsylvania State University)

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AFFILIATION AGREEMENT COVER SHEET / Checklist Please complete (Pennsylvania State University)

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Rev. 1/2017-klw
Please complete the following information and return to: Karen Wynn, Paralegal, The Pennsylvania State
University, Office of General Counsel, 108 Old Main, University Park, PA 16802, klh40@psu.edu
AFFILIATION AGREEMENT COVER SHEET / Checklist
Please complete the following information and return to: Karen Wynn, Paralegal, The Pennsylvania State
University, Office of General Counsel, 108 Old Main, University Park, PA 16802, klh40@psu.edu
1. Today’s Date: ____________________________
2. Agreement Start and End Date: ___________________ to ___________________________
3. Other PARTY/SITE Name: ____________________________________________________
4. PSU Program: _______________________________________
5. Type of Program: _____ Clinical _____ Non-Clinical
6. Does your program/department utilize www.castlebranch.com? ____ No ____ Yes
If No, please note that students will be required to directly provide evidence of any required
clearances, immunizations, health insurance, etc. to the Other Party/SITE. PSU will not provide
or maintain such information for the students.
7. Will PSU Faculty be ON-SITE directly supervising the student? ____ No ____ Yes
8. Is this for an IN-BOUND student to intern at a PSU facility? ____ No ____ Yes
If Yes, please note that applicable PSU policies will need to be approved by your HR
Representative (HR99, AD39 and/or AD72). If applicable, this will be explained further.
9. For International matters, please contact the Office of Global Programs’ Grants and Contracts
Administrator.
10. Is your program subject to any rules or regulations of an accrediting body? ____ No ____ Yes
If Yes, please note any specifications not included. Example: Is there a term limit for the
agreement?
__________________________________________________________________________________
11. Please provide any additional information that you believe will be helpful for our review:
__________________________________________________________________________________
__________________________________________________________________________________
12. Have you read and edited the Agreement as necessary before submitting it for review?
We rely on the University Program Coordinator to review the academic program requirements delineated
in the Agreement. Please review the entire agreement carefully for these program-specific provisions and
identify whether they are accurate by marking them as 1) yes, you do provide them, 2) no, you don’t
provide, or 3) make revisions as needed to make them accurate (this will help speed the process). For
example, if a provision requires that students must have completed a particular type of training (such as
OSHA or blood borne pathogen training) prior to participating in the program, please write in the margin
either “yes”, “no” or revise the statement to make it accurate.
____ No ____ Yes
AFFILIATION AGREEMENT
Office of General Counsel
The Pennsylvania State University
108 Old Main
University Park, PA 16802
Department Contact Information:
College/Admin Area/Campus: ________________________________________________
Contact Person: ____________________________________________________________
Phone Number: _______________________ E-mail Address: ______________________
Mailing Address: ___________________________________________________________
Site/OTHER PARTY Contact Information:
Contact Person: ____________________________________________________________
Phone Number: _______________________ E-mail Address: ______________________
Affiliation Agreement Cover Sheet Information
Send all Affiliation Agreements to: Karen Wynn, Paralegal, The Pennsylvania State University,
Office of General Counsel, 108 Old Main, University Park, PA 16802, klh40@psu.edu
Please note before passing an Agreement to us:
For out-bound students, the University typically does not require there to be an Agreement with an
internship site. Most clinical placements will require an Agreement.
o Where a clinical site or internship site requires an Agreement, the Agreement must be
reviewed by the Office of General Counsel (“OGC”). In such instances, students and
departments should plan at least one semester ahead of the intended start date. Students
should also have a back-up plan in case an Agreement cannot be reached.
Insurance – The University does not provide professional or general liability insurance for students
engaging in internships.
Notices/Contact information – Please fill in your name/Program Coordinator’s name and the Other
Party’s Contact information. It is best that the Program Coordinator stay updated regarding
information from the site/facility.
Please fill in all other blanks and spaces where appropriate.
Routing Instructions:
If you receive a signed original, please scan the Agreement and send it, along with the completed
cover sheet, to the email address provided above. If a scanner is not available, please send the
Agreement and cover sheet via inter-office mail to the address above.
If the Agreement is not signed or an original, please send the Agreement and cover sheet to the email
address provided above.
o If revisions are necessary, OGC will return revised Agreement to the Other Party for their
review, and copy the University Program Coordinator.
Agreements reviewed and approved by OGC will be forwarded to the Assistant Treasurer for
signature. Signed agreements will be forwarded to the University Program Coordinator.
Copies are not maintained by the OGC or Assistant Treasurer. Your office must keep a copy of this
Agreement on file as the official University copy.
Common Issues that delay the Process:
Information in the Agreement that is left blank and not filled-in by the sponsoring office or
department.
If the Agreement requires an address, please use the Program Coordinator/office address for the
sponsoring college, department or campus of The Pennsylvania State University.
If the Other Party has already signed the Agreement, only Agreements with original signature are
acceptable. Copies, including faxed copies, are not acceptable.
When all mentioned exhibits, policies, terms conditions, rules, etc., are not sent with the Agreement.
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AFFILIATION AGREEMENT COVER SHEET Checklist Please complete (Pennsylvania State University)

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Completed 10 November 2020

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