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Clinical-affiliation-agreement - Clinical Agreement revised

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U.S.A. forms for Southwest Tennessee Community College

BROWSE SOUTHWEST TENNESSEE COMMUNITY COLLEGE FORMS

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Purchasing+and+Auxiliary+Services+
Clinical+Affiliation+Agreement+Between+Southwest+Tennessee+Community+College+and+
________________________________________________________________________________
This!Agreement!is!made!this!____!day!of!___________,!20____,!by!and!between!Southwest!Tennessee!Community!
College,!hereinafter!referred!to!as!“College”!and!_______________________!herein!after!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!College,!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!in the
_________________________!program!of!the!College.
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!to!the!students!is!described!as!follows: .
Terms+and+Conditions-!pursuant!to!the!above-stated!purpose,!the!parties!agree!as!follows:!
A. Term-!the!term!of!this!Agree m en t!shall!be !(from !on e!to !five!years )!com m e ncin g!__ __ __ __ __ ___ __ ,
and!ending!_______________________.
Either!party!may!terminate!this!Agreement!upon!giving!______________,!days!written!notice!to!the
other!party.!Such!termination!shall!have!no!eff ec t!o n !st ud e n ts !rec eiv in g !clin ic al!e x p erie n ce !d u rin g !th e
current!academic!term.
This!Agreement!may!be!renewed!with!w ritten!ap p rov al!of!all!pa rties!fo r!a!tota l!term !of!up !to!five
years.
B. Placement!of!Students-!As!mutually!agreed!the!parties;!the!College!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!College!and!the!Affiliate.
Students!shall!be!dismissed!from!participation!in!the!College’s!program!only!after!the!appropriate
disciplinary!or!academic!policies!and!procedures!of!the!College!have!been!followed.!Howev er,!th e
Affiliate!may!immediately!remove!from!the!Facility!any!student!who!poses!an!immediate!threat!or
danger.
!
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D. Specific!Responsibilities!–!The!following!duties!shall!be!specific!responsibility!of!the!designated!party!
(College!and!/!or!F ac ility):!!
1. College!shall!be!responsible!for!the!selection!of!students!to!be!placed!at!the!Facility.!!
!
2. The!(☐!!!College!/!☐!!!Facility)!shall!provide!orientation!to!the!Facility!for!students!beginning!
clinical!experience.!!
!
3. The!(☐!!!College!/!☐!!!Facility)!shall!be!responsible!for!scheduling!training!activities!for!students.!!
!
4. The!(☐!!!College!/!☐!!!Facility)!shall!be!responsible!for!supervising!students!at!all!times!while!
present!at!the!Facility!for!clinical!experience.!!
!
5. The!(☐!!!College/☐!!!Facility)!shall!evaluate!the!performance!of!individual!stu dents!as!appropriate.!!
!
6. The!(☐!!!College!/!☐!!!Facility)!shall!retain!complete!responsibility!for!patient!care!providing!
adequate!supervision!of!students!(and!faculty,!if!applicable)!at!all!times.!!
!
7. The!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.!!
!
8. The!Affiliate!shall!provide!emergency!medical!treatment!to!students!(and!faculty,!if!applicable)!if!
needed!for!illness!or!injuries!suffered!during!clinical!experience.!Such!treatment!shall!be!at!the!
expense!of!the!individual!treated.!!
!
9. The!Affiliate!shall!maintain!all!applicable!accreditation!requirements!and!certify!such!compliance!
to!the!College!or!oth er!en tity!as!requ es ted!b y!the !Co llege.!Th e!A ffiliate!shall!also !permit!
authorities!responsible!for!accreditation!of!the!College’s!curriculum!to!inspect!the!Affiliate’s!
clinical!facilities!and!services!as!necessary.!!
!
10. The!College!shall!provide!health!records!of!students!(and!faculty,!if!applicable)!upon!request!by!
the!Affiliate.!!
!
11. The!College!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!training.!
!!
12. The!College!may!provide!written!evidence!of!professional!liability!insurance!coverage!from!
individua l!stu d e n ts!a n d !fa c u lty!a n d !st af f!(if!a p p lica b le )!p a rtic ip at in g!in!the !ex p er ien c e.!T h e !
minimum!amount!of!coverage!per!individual!shall!be!$2,000,000.00!per!occurrence!and!
$5,000,000.00!in!aggregate.!!
!
The!coverage!shall!extend!through!the!term!of!the!students!and!faculty!or!staffs!(if!applicable)!
participation.!
!!
13. The!State!of!Tennessee!is!self-insured!an d !d o es !n o t!ca rr y!o r!maintain!c o mmercial!g en e ra l!liab ilit y!
insurance !o r!medical,!pro f ess io n a l!o r!h o sp ita l!lia b ility!in s u ra n ce .!A n y!a n d !a ll!cla ims!against !th e!
State!of!Tennessee,!including!the!College!or!its!employees,!shall!be!hear d !a n d !d e te rmined!b y!t h e !
Tennessee!Claims!Commission!in!the!manner!prescribed!by!law.!Damages!recoverable!against!
the!College!shall!be!exp res sly!limited !to!claim s!p aid !by!th e!Claim s!C om mission!pursuan t!to!T .C.A!
Section!9-8-307!et!seq.!!
E. Mutual!responsibilities!–!The!parties!shall!cooperate!to!fulfill!the!following!mutual!responsibilities.!!
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1. Each!party!shall!comply!with!all!federal,!state!and!municipal!laws,!advice,!and!regulations!that!
are!applicable!to!the!performance!of!this!Agreement,!which!shall!include!but!not!limited!to:!!
!
HIPAA!Requirements:!To!the!extent!required!by!federal!law,!the!parties!agree!to!comply!with!the!
Health!Insurance!Portability!and!Accountability!Act!of!1996,!as!codified!at!42!U.S.C.!Section!
1320d!(“HIPAA”)!and!any!current!and!future!regulatio ns!p rom u lga ted!th ereu n de r,!includ ing!
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 !H e a lth !In fo r m a tio n ,!o t h er !th a n !as !p e rmitted!by!H IP A A !R e q u ire ments!and !t h e!t er m s !
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.!!
!
2. Backgrounds!Checks:!If!crimina l!b a ck g ro u n d !ch e c ks !o f!s tu d e n ts !ar e!r eq u ir ed !b y !th e !A ffilia te ,!th e !
College!shall!notify!students!of!this!requirement!prior!to!enrollment!in!the!program!or!as!soon!as!
the!requiremen t!is!kno w n.!Stu d en ts!will!be !inform e d!b y!the !Co llege!tha t!the!ch eck!must!be!
completed!within!the!90-day!period!immediately!prior!to!the!student’s!initial!clinical!placement.!
It!shall!be!th e !st u d en t ’s!re s p o n sib ilit y!to !make!tim e ly!a rra n g e m e n ts !fo r!t h e!b a c kg ro u n d !c h e ck !
and!to!pay!all!costs!associated!with!such!checks.!
!!
If!criminal!back gro un d !ch eck s!are !req uire d!fo r!Collegial!faculty!or!staff,!it!shall!be!the!C o llege’s!
responsibility!to!arran ge !for!the!b ack gro un d !chec k,!to!pa y!all!costs !asso ciate d!w ith!su ch !chec ks!
and!to!provide!the!results!to!the!Affiliate.!
!!
It!shall!be!the !resp on sibility!o f!the!Affiliate !to!set!the !eligibility!stan da rds !for!particip atio n!an d !to!
evaluate!the!results!of!the!background!checks.!If!Affiliate!determines!that!a!student!or!
faculty/staff!member!shall!not!p articip ate !at!its!fac ility,!Affiliate!sh all!n o tify!t h e!in d iv id u al!a n d !th e !
College.!College!shall!take!steps!to!ensure!that!this!individual!does!not!participate!in!the!clinical!
program!at!the!Affiliate.!
!!
If!a!Collegial!faculty/staff!membe r!is!also!a n!e m p loye e!o f!Affiliate !or!is!a nd !employee!at!another!
hospital,!health!care!facility!or!health!care!organization,!Affiliate!will!allow!the!faculty/staff!
member!to!provide!on-site!supervision!and!instruction!for!its!clinical!program!without!the!
necessity!of!undergoing!an!additional!background!check.!
!!
Recognizing!that!students!enrolled!in!the!______________!Program!at!College!will!potentially!
participate!in!multiple!clinical!placements!at!multiple!facilities,!Affiliate!agrees!to!accept!the!
results!of!the!backgro un d !chec k!do n e!prio r!to!the !stud en t’s!initial!c lin ica l!p la ce ment!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.!
!!
College!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.!!
!
[If!desired,!a!list!of!check s!to!b e!ru n,!a lon g!w ith!th e!d isq ua lifying !criteria!o f!the !Affiliate !can !b e!
referenced!and !affixed !as!an !Ad d en du m .]!!
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3. Students!shall!be!treated!as!trainees!who!have!no!expectation!of!receiving!compensation!or!
future!emplo yment!from!th e!Affiliate !or!Co llege.!
!!
4. Any!courtesy!appointments!to!faculty!or!staff!by!either!the!College!or!the!Affiliate!shall!be!
without!entitlement!of!the!individual!to!compensation!or!benefits!from!the!appointing!party.!!
!
5. The!parties!agree!to!comply!with!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 !again st!an !indiv idu al!inclu din g,!bu t!no t!limited !to,!
employees!or!applicants!for!employment!and!/or!students!because!of!race,!religion,!creed,!color,!
sex,!age,!disability,!veteran!status!or!national!origin.!!
!
The!parties!also!agree!to!take!affirma tive!a ction !to!en su re!tha t!app lican ts!are !em p loye d!a nd !tha t!
employees!are!treated!during!their!employment!without!regard!to!their!race,!religion,!creed,!
color,!sex,!age,!disability,!veteran!status,!or!national!origin.!Such!action!shall!include,!but!not!be!
limited!to,!th e !fo llo w in g :!employm e nt ,!up g ra d in g,!d e motion!or!t ra ns fe r,!rec ru itment!or!
recruitment!adv ertisin g,!layoff!o r!term in atio n,!rates!o f!pa y!or!o ther!fo rm s!o f!com p en sa tion ,!and !
selection!available!to!employees!and!applican ts!f o r!employm e n t.!!
!
6. The!confidentiality!of!patient!records!and!student!records!shall!be!m a inta ine d!at!all!tim es.!!
!
F. Miscellaneous!Terms!–!The!following!terms!shall!apply!in!the!interpretation!and!performance!of!this!
Agreement.!!
1. Neither!party!shall!be!responsible!for!personal!injury!or!pro pe rty!da m a ge!o r!loss!exc ept!th at!
resulting!from!its!ow n!n eglige nce !or!the !neg ligen ce!of!its!em p loy ees !or!oth ers!fo r!wh o m !the!
party!is!legally!responsible.!
!!
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!brea ch !of!this!Ag reement!shall!be!immediate!termina tion .!!
!
3. This!Agreement!shall!in!no!way!be!interpreted!as!creating!an!agency!or!employment!relationship!
between!the!parties.!!
!
4. This!Agreement!may!be!executed!in!two!or!more!counterparts,!each!of!which!together!shall!be!
deemed!an!original,!but!all!of!which!together!shall!constitute!one!and!the!same!instrument.!In!
the!event!that!any!sign atu re!is!delive red !by!facs im ile!transm iss ion !or!by !e-mail!delivery!a!“.pdf”!
format!data!file,!su ch !sign atu re!sh all!cre ate !a!va lid!an d !bin din g!o bliga tion !of!th e!p arty !exe cu ting !
(or!on!whose!behalf!such!signature!is!executed)!with!the!same!force!and!effect!as!if!such!
facsimile!or!“.pdf” !sign atu re!p ag e!was!an!original!thereof.!!
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In!witness,!whereof,!the!parties,!through!their!authorized!representatives,!have!affixed!their!signature!below.!
!!
! ! ! ! ! ! ! Southwest!Tennessee!Community!College!!
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By:!________________________________________!! By:!_____________________________________!
!
Name:!________________________________! ! Name:!!Dr.!Tracy!D.!Hall!
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Title:!_________________________________! ! Title:!!President!
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Date:!_________________________________! ! Date:!!__________________________________!
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Approval!of!contract,!which!materially!differ!from!this!form,!require!approval!of!the!Chancellor.!!
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Chancellor:!___________________________!! ! Date:!__________________________________!!
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Clinical-affiliation-agreement - Clinical Agreement revised

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Completed 16 November 2019

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