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CLINICAL EXPERIENCE AFFILIATION AGREEMENT
This Agreement is made by and between East Tennessee State University, hereinafter referred
to as "Institution" and _______________________________, hereinafter referred to as
"Affiliate".
Whereas, it is to the mutual benefit of the parties to provide clinical experience for students
enrolled in certain programs of the Institution, the parties have agreed to the terms and
provisions set forth below:
I. Purpose - the purpose of this Agreement shall be to provide clinical experience to
students enrolled at Institution.
A. Consideration for this Agreement shall consist of the mutual promises contained
herein, the parties agreeing that monetary compensation shall neither be
expected nor received by either party.
B.
The clinical experience shall be provided at the Affiliate's Facility located at
________________________
________________________,
hereinafter referred to as "Facility".
C. The specific experience to be provided students is detailed in Addendum to
Clinical Experience Affiliation Agreement, attached hereto.
II. Terms and Conditions - pursuant to the above-stated purpose, the parties agree as
follows:
A. Term - the term of this Agreement shall be commencing ______________
and
ending _______________.
Either party may terminate this Agreement upon
giving thirty (30) days written notice to the other party. Such termination shall
have no effect on students receiving clinical experience during the current
academic term. This Agreement may be for a total Agreement term of up to five
years.
B. Placement of Students As mutually agreed between the parties, the Institution
will place an appropriate number of students at the Facility each academic term.
C. Discipline - While enrolled in clinical experience at the Facility, students (and
faculty, if applicable), will be subject to applicable policies of the Institution and
the Affiliate. Students shall be dismissed from participation in the Institutions
program only after the appropriate disciplinary or academic policies and
procedures of the Institution have been followed. However, the Affiliate may
immediately remove from the Facility any student who poses an immediate
threat or danger.
D. Responsibilities of Affiliate The following duties shall be the specific
responsibility of the Affiliate:
1. Affiliate shall provide orientation to the Facility for students beginning
clinical experience.
2. Affiliate shall be responsible for scheduling training activities for
students.
3. Affiliate shall be responsible for supervising students at all time while
present at the Facility for clinical experience.
4. Affiliate shall evaluate the performance of individual students as
appropriate.
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5. Affiliate shall retain complete responsibility for patient care providing
adequate supervision of students at all times.
6. Affiliate shall maintain a sufficient level of staff employees to carry out
regular duties. Students will not be expected nor allowed to perform
services in lieu of staff employees.
7. Affiliate shall provide emergency medical treatment to students (and
faculty, if applicable) if needed for illness or injuries suffered during
clinical experience. Students will comply with all applicable facility
regulations to protect parties, co-workers, and themselves against
infections or environmental hazards or other occupational injuries.
Should a student be exposed to such hazards or injury in the facility,
Affiliate will comply with OSHA and other regulations to ensure proper
diagnosis and treatment of such exposure. Emergency treatment will
be provided at the expense of the student. Institution’s Office of
Student Affairs will assist students in arranging for appropriate
medical follow-up. However, the student will ultimately be responsible
for completing appropriate medical follow-up visits, necessary testing,
and for the expenses associated with these. The student’s
responsibilities in these circumstances are further addressed in the
college’s student handbook. Such treatment shall be at the expense of
the individual treated.
8. Affiliate shall maintain all applicable accreditation requirements and
certify such compliance to the Institution or other entity as requested
by Institution. Affiliate shall also permit authorities responsible for
accreditation of Institution’s curriculum to inspect Affiliate’s clinical
facilities and services as necessary.
9. Affiliate requires written evidence of professional liability insurance
coverage from individual students participating in the experience. The
minimum amount of coverage per individual shall be
__________________. The coverage shall extend through the term
of the student’s participation.
E. Responsibilities of the Institution - The following duties shall be the specific
responsibility of the Institution:
1. Institution shall be responsible for the selection of students to be placed
at the Facility.
2. Institution shall provide health records of students (and faculty, if
applicable) upon request by the Affiliate.
3. The Institution shall establish a procedure for notifying the Affiliate if
a student (or faculty, if applicable) is/are unable for any reason to
report for clinical experience.
4. The State of Tennessee is self-insured and does not carry or maintain
commercial general liability insurance, medical, or professional
liability insurance. Any and all claims against the State of Tennessee,
including the Institution or its employees, shall be heard and
determined by the Tennessee Claims Commission in the manner
prescribed by law. Damages recoverable against the Institution shall be
expressly limited to claims paid by the Claims Commission pursuant to
T.C.A. § 9-8-301 et seq.
F. Mutual responsibilities - the parties shall cooperate to fulfill the following mutual
responsibilities:
1. Affiliate and Institution will work collaboratively to monitor the
learning environment and to ensure that an appropriate learning
environment is established for medical education. The learning
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environment should foster development of appropriate professional
attributes in medical students. This includes recognition that
professional behavior by students, faculty, hospital staff, and medical
staff are important components of the learning environment. Both
formal learning activities and the attitudes, values, and informal
“lessons” conveyed by individuals who interact with the medical
student are important factors contributing to the development of
appropriate attitudes, behaviors, and professional identity.
2. Each party shall comply with all federal, state and municipal laws,
advice, rules and regulations which are applicable to the performance
of this Agreement, which shall include but not be limited to:
a. To the extent required by federal law, the Health Insurance
Portability and Accountability Act of 1996, as codified at 42 U.S.C.
Section 1320d (“HIPAA”) and any current and future regulations
promulgated thereunder, including without limitation, the federal
privacy regulations, the federal security standards, and the federal
standards for electronic transactions, all collectively referred to
herein as “HIPAA Requirements.” The parties agree not to use or
further disclose any Protected Health Information or Individually
Identifiable Health Information, other than as permitted by
HIPAA Requirements and the terms of this Agreement. Each party
will make its internal practices, books, and records relating to the
use and disclosure of Protected Health Information available to the
Secretary of Health and Human Services to the extent required for
determining compliance with the Federal Privacy Regulations.
b. Titles VI and VII of the Civil Rights Act of 1964, Title IX of the
Education Amendments of 1972, and Section 504 of the
Rehabilitation Act of 1973, Executive Order 11,246, the Americans
with Disabilities Act of 1990 and the related regulations to each.
Each party assures that it will not discriminate against any
individual including, but not limited to, employees or applicants
for employment and/or students because of race, religion, creed,
color, sex, age, disability, veteran status or national origin.
c. The Family Educational Rights and Privacy Act (FERPA). The
Affiliate shall protect the confidentiality of the student’s records
and shall not release any information without written consent
from the student unless required to do so by law.
3. Background Checks: If criminal background checks of students are
required by the Affiliate, the Institution shall notify students of this
requirement prior to enrollment in the program or as soon as the
requirement is known. Students will be informed by the Institution that
the check must be completed within the 90 day period immediately
prior to the student’s initial clinical placement. It shall be the student’s
responsibility to make timely arrangements for the background check
and to pay all costs associated with such checks.
a. It shall be the responsibility of Affiliate to set the eligibility
standards for participation and to evaluate the results of
the background checks. If Affiliate determines that a
student or faculty/staff member shall not participate at its
facility, Affiliate shall so notify that individual and the
Institution. Institution shall take steps to ensure that this
individual does not participate in the clinical program at
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the Affiliate.
b. Recognizing that students enrolled at Institution will
potentially participate in multiple clinical placements at
multiple facilities, Affiliate agrees to accept the results of
the background check done prior to the student’s initial
clinical placement if the student maintains continuous
enrollment in the health care program and if the results of
the background check are archived by the background
check agency.
c. Institution shall inform students or faculty/staff members
excluded from clinical placement on the basis of a criminal
background check of any review or appeal process
available pursuant to the Fair Credit Reporting Act or any
other law or policy, if any.
4. Students shall be treated as trainees who have no expectation of
receiving compensation or future employment from the Affiliate or the
Institution.
5. The confidentiality of patient records and student records shall be
maintained at all times.
G. Miscellaneous Terms - The following terms shall apply in the interpretation and
performance of this Agreement:
1. Each party shall be solely liable for payment of its portion of all claims,
liability, costs, expenses, demands, settlements, or judgments resulting
from negligence, actions or omissions of itself or those for whom it is
legally responsible relating to or arising under this Agreement. Any
and all monetary claims against the State of Tennessee, its officers,
agents, and employees in performing any responsibility specifically
required under the terms of this Agreement shall be submitted to the
Board of Claims or the Claims Commission of the State of Tennessee
and shall be limited to those provided for in T.C.A. 9-8-307.
2. The delay or failure of performance by either party shall not constitute
default under the terms of this Agreement, nor shall it give rise to any
claims against either party for damages. The sole remedy for breach of
this Agreement shall be immediate termination.
3. This Agreement shall in no way be interpreted as creating an agency or
employment relationship between the parties.
In witness whereof, the parties, through their authorized representatives, have affixed their
signatures below.
________________________________
Signature:_____________________________
Title:________________________________
Date:________________________________
EAST TENNESSEE STATE UNIVERSITY
Signature:_____________________________
Title:________________________________
Date:________________________________
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ADDENDUM TO CLINICAL AFFILIATION AGREEMENT
1. Academic Program: _______________________________
2. Persons Coordinating Clinical Experience:
Institution:
Name: __________________________________
Telephone: __________________________________
Email: __________________________________
Affiliate:
Name: __________________________________
Telephone: __________________________________
Email: __________________________________
3. Number of Students Participating: ________________
4. Training Dates: _____________________________
5. Description of training and specific experience: ________________________
_________________________________________________________
__________________________________________________________
6. Other: _____________________________________________________