HomeMy WebLinkAboutEIRMC School Affiliation Agreement 2016-17(non-medical students only)1 Revised 01-2016 / School Affiliation for Non-Medical Students ONLY
SCHOOL AFFILIATION AGREEMENT
THIS SCHOOL AFFILIATION AGREEMENT (this “Agreement”) is made as of September, 2016 (the
“Effective Date”) by and between School District 93 ("School") and Eastern Idaho Regional Medical
Center ("Hospital"). School and Hospital may be referred to herein individually as a “Party” and
collectively as the “Parties.”
W I T N E S S E T H:
WHEREAS, School enrolls students in an accredited degree program in the field of Certified Nursing
Assistant (the “Degree Program”);
WHEREAS, Hospital operates a comprehensive acute-care medical-surgical hospital located at 3100
Channing Way, Idaho Falls, ID 83404 (the “Facility”);
WHEREAS, School desires to provide students enrolled in the Degree Program a clinical learning
experience through the application of knowledge and skills in actual patient-centered treatment situations
in a health care setting; and
WHEREAS, Hospital will make the Facility available to School for such clinical learning experience,
subject to the terms and conditions of this Agreement.
NOW, THEREFORE, in consideration of the mutual promises contained herein, the Parties hereby
agree as follows:
1. RESPONSIBILITIES OF SCHOOL.
(a) Clinical Program. School will develop, implement and operate the clinical learning experience
component of the Degree Program at the Facility in a form and format acceptable to Hospital
("Clinical Program"). School may modify the Clinical Program from time to time with Hospital’s
permission and will promptly incorporate reasonable changes to the Clinical Program
requested by Hospital from time to time. With respect to the Clinical Program, School will:
(i) ensure the adequacy of Degree Program resources, including up-to-date reference
materials, and the academic preparation of students enrolled in the Degree Program,
including theoretical background, basic skills, professional ethics, and attitude and
behavior, for participation in the Clinical Program and will assign to the Clinical Program
only those students who have demonstrated the ability to successfully participate in the
Clinical Program (each a “Participating Student”);
(ii) provide training and orientation and document the provision of such training and
orientation for each Program Participant (defined below) with respect to applicable
Hospital policies and procedures prior to the commencement of each Clinical Program
rotation during the Term (each a “Semester Rotation”);
(iii) provide training for Hospital’s representatives who will support the Clinical Program
regarding Clinical Program features and expectations, and Participating Student
evaluations, as requested by Hospital from time to time;
(iv) identify to Hospital each Program Participant who will participate in a Semester Rotation
as soon as that information is reasonably available to School;
(v) ensure that Program Participants comply with applicable laws and Hospital policies and
procedures when onsite at the Facility;
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(vi) ensure that Program Participants treat Hospital patients, staff and Clinical Program
supervisors with courtesy and respect and do not disrupt Facility operations or the
provision of health care services for Hospital’s patients;
(vii) timely prepare and update with input from Hospital rotation schedules for each
Participating Student throughout each Rotation and coordinate the same with Hospital;
(viii) ensure that Participating Students arrive early for each scheduled rotation, except when
a Participating Student is ill or attending to a personal emergency;
(ix) provide continuing oral and written communication with Hospital regarding Participating
Student Clinical Program performance and evaluation and other pertinent information;
(x) participate and ensure that Program Participants participate in Hospital's Quality
Assurance and related programs;
(xi) participate and ensure that Program Participants participate in Hospital training as
determined necessary by Hospital from time to time; and
(xii) promptly perform additional duties to facilitate operation of the Clinical Program as may
be deemed reasonable or necessary by Hospital from time to time.
(b) Responsibility.
(i) School will retain ultimate responsibility for the appointment of faculty from the Degree
Program to support the Clinical Program, for educating and supervising Participating
Students and for evaluating Participating Students’ performance with respect to the Clinical
Program.
(ii) Without limiting the foregoing, all Participating Students, Degree Program faculty and other
School representatives onsite at the Facility (collectively “Program Participants”) shall be
accountable to the Hospital's Administrator while onsite at the Facility.
(iii) School will address all Program Participant complaints, claims, requests and questions
regarding the Clinical Program. If necessary, School’s Program Representative will follow-
up with Hospital’s Program Representative to address unresolved issues.
(c) Compliance with Program Requirements. School acknowledges that compliance by School
and each Program Participant with the terms and conditions of this Agreement and Hospital
policies and procedures is a condition precedent to Program Participant access to the Facility.
Non-compliance or partial compliance with any such requirement may result in an immediate
denial of access or re-access to the Facility.
(d) Dress Code. School will cause Program Participants to conform to reasonable personal
appearance standards imposed by Hospital and wear ID badges as requested by Hospital from
time to time. School will cause Program Participants to pay for their own meals at the Facility.
School acknowledges and will regularly inform Program Participants that Hospital is not
responsible for personal items lost or stolen at the Facility.
(e) Use of the Facility School will ensure that Program Participants use the Facility solely for the
purpose of providing to Participating Students clinical learning experience pursuant to the
Clinical Program.
(f) Records. School will cause each Program Participant to timely complete and save in
Hospital’s systems as directed by Hospital accurate records of all services provided by the
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Program Participant to a Hospital patient ("Records"). All Records are and will remain the
property of Hospital, subject to the rights of patients with respect to such records and to the
terms of applicable law. Hospital will provide to School a copy of Records for all lawful
purposes, including defense of liability claims.
(g) Program Participants. School will provide to Hospital information regarding each Program
Participant, including health examination and immunization records, documentation attesting
to the competency of Degree Program faculty (e.g., state licensure, board certification in the
relevant Specialty, etc.) and background checks and drug screens as determined reasonably
necessary in Hospital’s discretion from time to time.
(h) Program Participant Statements. School shall require each Program Participant to sign a
Statement of Responsibility, in the form attached hereto as Exhibit A, and a Statement of
Confidentiality and Security, in the form attached hereto as Exhibit B prior to each Semester
Rotation.
(i) Liability Insurance. School shall obtain and maintain occurrence-type general and
professional liability insurance coverage in amounts not less that one million dollars
($1,000,000.00) per occurrence and three million dollars ($3,000,000.00) annual aggregate per
Program Participant, with insurance carriers or self insurance programs approved by Hospital
and covering the acts and omissions of Program Participants. If such coverage is provided on
a claims-made basis, then such insurance shall continue throughout the Term and upon the
termination or expiration of this Agreement, School shall purchase tail coverage for a period of
three years after the termination or expiration of this Agreement (said tail coverage shall be in
amounts and type equivalent to the claims-made coverage). School shall further, at its
expense, obtain and maintain for the Term workers' compensation insurance and
unemployment insurance for School-employed Program Participants. School will notify
Hospital at least thirty (30) calendar days in advance of any cancellation or modification of
insurance coverage required hereunder and shall promptly provide to Hospital, upon request,
certificates of insurance evidencing the above coverage.
(j) Health of Program Participants. School will ensure that each Program Participant submits
to a medical examination acceptable to Hospital prior to each Semester Rotation. School will
ensure that each Program Participant maintains health insurance and provides proof of health
insurance to the School prior to participating in the Clinical Program. School will cause
Program Participants to provide to Hospital proof of health insurance as requested by Hospital
from time to time. School acknowledges that as between Hospital and School, School is
responsible for arranging for each Program Participant's medical care and/or treatment,
including transportation, in case of illness or injury while participating in the Clinical Program.
School further acknowledges that Hospital is not and will not be financially responsible for a
Program Participant's medical care or treatment regardless of the Program Participant's
condition or injury or cause of injury whether occurring at the Facility or otherwise and
regardless of fault or cause of injury.
School will ensure that each Participating Student furnishes to Hospital prior to each Semester
Rotation a complete copy of the following health records (Participating Students will not be
allowed to access the Facility until all records are provided):
(i) Tuberculin skin test performed within the past twelve (12) months or
documentation as a previous positive reactor;
(ii) Proof of Rubella and Rubeola immunity by positive antibody titers or two (2) doses
of MMR;
(iii) Proof of Varicella immunity, by positive history of chickenpox or Varicella
immunization;
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(iv) Proof of Influenza vaccination during the flu season, October 1 to March 31, (or
dates defined by CDC), or a signed Declination Form; and
(v) Proof of Hepatitis B immunization or declination of vaccine, if patient contact is
anticipated.
(k) Performance. All faculty provided by School to support the Clinical Program shall be faculty
members of the Degree Program, duly licensed, certified or otherwise qualified to support the
Clinical Program in the capacity proposed by School. School and all Program Participants shall
perform its and their duties and services hereunder in accordance with all relevant local, state,
and federal laws and shall comply with the standards and guidelines of all applicable
accrediting bodies and the bylaws, rules and regulations of Hospital and any non-conflicting
rules and regulations of School as may be in effect from time to time. Neither School nor any
Program Participant shall interfere with or adversely affect the operation of Hospital or the
performance of services therein.
(l) Background Checks.
(i) School will ensure that each Program Participant obtains prior to each Semester
Rotation a background check acceptable to Hospital, including, at a minimum, the
following:
A. Social Security Number Verification;
B. Criminal Search (7 years or up to 5 criminal searches);
C. Employment Verification to include reason for separation and eligibility for re-
employment for each employer for 7 years (not required for students younger
than 21 years of age);
D. Sex Offender and Predator Registry Search;
E. HHS/OIG Exclusions Database;
F. GSA List of Parties Excluded from Federal Programs;
G. U.S. Treasury, Office of Foreign Assets Control (OFAC), List of Specially
Designated Nationals (SDN); and
H. Applicable State Exclusion List, if available.
(ii) Background Checks for Program Participants who will be treating patients in the
Facility shall include all of the above, and the following:
A. Education verification (highest level);
B. Professional license verification;
C. Certifications & Designations check;
D. Professional Disciplinary Action search;
E. Department of Motor Vehicle Driving History, based on responsibilities; and
F. Consumer Credit Report, based on responsibilities.
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(iii) School shall provide to Hospital an Attestation of Satisfactory Background
Investigation in the form attached hereto as Exhibit C prior to each Semester
Rotation. If the background check discloses adverse information about a
Participating Student, School shall immediately remove the student from the
Clinical Program.
(m) Drug and Alcohol Testing. School will ensure that each Program Participant obtains prior to
each Semester Rotation a drug and alcohol test acceptable to Hospital, including, at a
minimum, the following:
(i) Substances tested must include amphetamines, barbiturates, benzodiazepines,
opiates, fentanyl analogues, methadone, marijuana, codeine, and cocaine.
(ii) A Program Participant may be required to undergo additional drug and alcohol
testing upon reasonable suspicion that the Program Participant has violated
Hospital's policies, and after any incident that involves injury or property damage.
Hospital shall not bare the cost of any such tests.
(n) Student Documentation. School will maintain all documentation required to evidence
compliance by each Program Participant with the terms and conditions of
Subsections 1(g)- (m) of this Agreement during the Term and for at least ten (10) years
following expiration or termination of this Agreement.
(o) Access to Resources. The School shall ensure that its department heads have authority to
ensure faculty and Participating Student access to appropriate resources for the Participating
Students’ education.
2. RESPONSIBILITIES OF HOSPITAL .
(a) Hospital will make Facility access reasonably available to Program Participants and reasonably
cooperate with School’s orientation of all Program Participants to the Facility. Hospital shall
provide Program Participants with access to appropriate clinical experience resources for the
Clinical Program. Hospital shall provide reasonable opportunities for Participating Students to
observe and assist in various aspects of patient care to the extent permitted by applicable law
and without disruption of patient care or Hospital operations. Hospital shall at all times retain
ultimate control of the Hospital and responsibility for patient care and quality standards.
(b) Upon the request of School, Hospital shall assist School in the evaluation of each Participating
Student’s performance in the Clinical Program. Any such evaluations shall be returned to
School in a timely manner. However, School shall at all times remain solely responsible for the
evaluation and education of Participating Students.
(c) Hospital will ensure that the Facility complies with applicable state and federal workplace safety
laws and regulations. In the event a Participating Student is exposed to an infectious or
environmental hazard or other occupational injury (i.e., needle stick) while at the Facility, it shall
provide, upon notice of such incident from the Participating Student, such emergency care as
is provided its employees, including, where applicable: examination and evaluation by Facility’s
emergency department or other appropriate facility as soon as possible after the injury;
emergency medical care immediately following the injury as necessary; initiation of the HBV,
Hepatitis C (HCV), and/or HIV protocol as necessary; and HIV counseling and appropriate
testing as necessary. In the event that the Facility does not have the resources to provide such
emergency care, Facility will refer such student to the nearest emergency facility.
(d) To the extent Hospital generates or maintains educational records for Participating Students
that are subject to the Family Educational Rights and Privacy Act (FERPA), Hospital will comply
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with applicable FERPA requirements. For purposes of this Agreement, School shall designate
Hospital as a school official with a legitimate educational interest in the educational records of
Participating Students to the extent that access to School's records is required by Hospital to
carry out the Clinical Program.
(e) Upon reasonable request, Hospital will provide proof to School that Hospital maintains liability
insurance in an amount that is commercially reasonable.
(f) Hospital will provide written notification to School if a claim arises involving a Program
Participant. Both Hospital and School agree to share such information in a manner that protects
such disclosures from discovery to the extent possible under applicable federal and state peer
review and joint defense laws.
(g) Hospital will resolve any situation in favor of its patients' welfare and may restrict a Participating
Student to the role of observer when necessary in Hospital’s discretion. Hospital will notify
School's Program Representative (defined below) when such action has occurred.
(h) Upon reasonable notice from School, Hospital will make the Facility reasonably available for
inspection during normal business hours by organizations that provide or may provide
academic accreditation for the Degree Program. Such inspections must be accompanied at
all times by a Hospital representative and are contingent upon receipt by Hospital of executed
agreements that Hospital believes are reasonably necessary or convenient to protect the
confidentiality and security of Hospital’s information. School will promptly reimburse Hospital
for all direct costs incurred by Hospital in connection with such accreditation inspections.
(i) Hospital shall provide Program Participants with access to and Participating Students with
required training in the proper use of electronic medical records or paper charts, as applicable.
(j) Hospital shall provide student security badges or other means of secure access to Facility
patient care areas.
(k) Hospital shall provide Program Participants with computer access, and access to call rooms, if
necessary.
(l) Hospital shall provide secure storage space for Participating Students’ personal items when at
the Facility.
(m) Hospital shall provide qualified and competent staff members in adequate number for the
instruction and supervision of students using the Facility.
3. MUTUAL RESPONSIBILITIES. The Parties shall cooperate to fulfill the following mutual responsibilities:
(a) Each Party will identify to the other Party a Clinical Program representative (each a “Program
Representative”) on or before the execution of this Agreement. School’s Program
Representative shall be a faculty member who will be responsible for Participating Student
teaching and assessment provided pursuant to this Agreement. Each Party will maintain a
Program Representative for the Term and will promptly appoint a replacement Program
Representative if necessary to comply with this Agreement. Each Party will ensure that its
Program Representative is reasonably available to the other Party’s Program Representative.
(b) School will provide qualified and competent Degree Program faculty in adequate number for
the instruction, assessment and supervision of Participating Students at the Facility.
(c) Both School and Hospital will work together to maintain a Clinical Program emphasis on high
quality patient care. At the request of either Party, a meeting or conference will promptly be
held between the Parties’ respective Program Representatives to resolve any problems in the
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operation of the Clinical Program.
(d) School acknowledges, and will inform Participating Students that Participating Students are
trainees in the Clinical Program and have no expectation of receiving compensation or future
employment from Hospital or School. Participating Students are not to replace Hospital staff
and are not to render unsupervised patient care and/or services. Hospital and its staff will
provide such supervision of the educational and clinical activities as is reasonable and
appropriate to the circumstances and to the Participating Student’s level of training.
(e) Any courtesy appointments to faculty or staff by either School or Hospital shall be without
entitlement of the individual to compensation or benefits for the appointed party.
(f) Both School and Hospital will work together to create and maintain an appropriate learning
environment for the Participating Students.
(g) The School, including its faculty, staff and residents, and the Hospital share responsibility for
creating an appropriate learning environment that includes both formal learning activities and
the attitudes, values, and informal "lessons" conveyed by individuals who interact with the
Participating Student. The parties will cooperate to evaluate the learning environment (which
may include on-site visits) to identify positive and negative influences on the maintenance of
professional standards, and to conduct and develop appropriate strategies to enhance the
positive and mitigate the negative influences.
4. WITHDRAWAL OF PARTICIPATING STUDENTS. Hospital may immediately remove a Participating
Student from the Facility when in Hospital’s discretion his or her clinical performance is unsatisfactory or
his or her behavior is disruptive or detrimental to Hospital operations and/or Hospital’s patients. In such
event, School will immediately remove the Participating Student from the Clinical Program. It is understood
that only School can dismiss the Participating Student from the Clinical Program. School may terminate a
Participating Student’s participating in the Clinical Program when it determines, in its sole discretion, that
further participation by the student would no longer be appropriate.
5. FEES. All fees generated by or in connection with services provided by Program Participants to
Hospital patients belong to Hospital. School on behalf of itself and each Program Participant hereby
assigns to Hospital all right, title and interest (if any) in and to such fees. If School or any Program
Participant receives any fees or other reimbursement for services provided by Program Participants to
Hospital patients, School will and will cause Program Participants to immediately deliver and endorse over
to Hospital all such amounts. School will and will cause Program Participants not to bill Hospital patients
for services provided. School will and will cause Program Participants to take all actions and execute all
documents reasonably requested by Hospital in order for Hospital to collect fees and payments for health
care services provided by Program Participants.
6. INDEPENDENT CONTRACTOR; NO OTHER BENEFICIARIES; EMPLOYMENT DISCLAIMER.
(a) The Parties hereby acknowledge that they are independent contractors, and neither School
nor any of its agents, representatives, Program Participants, or employees shall be considered
agents, representatives, or employees of Hospital. In no event shall this Agreement be
construed as establishing a partnership or joint venture or similar relationship between the
Parties. School shall be liable for its own debts, obligations, acts and omissions, including the
payment of all required withholding, social security and other taxes or benefits. No Program
Participant shall look to Hospital for any salaries, insurance or other benefits. No Program
Participant or other third person is entitled to, and shall not, receive any rights under this
Agreement. Neither Party shall have the right or authority nor hold itself out to have the right
or authority to bind the other Party and neither shall either Party be responsible for the acts or
omissions of the other except as provided specifically to the contrary herein.
(b) Each Party acknowledges Participating Students will not be considered employees or agents
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of Hospital or School for any purpose. Participating Students will not be entitled to receive any
compensation from Hospital or School or any benefits of employment from Hospital or School,
including health care or workers’ compensation benefits, vacation, sick time, or other direct or
indirect benefit of employment.
(c) School acknowledges that Hospital has not and is not obligated to implement or maintain
insurance coverage for the benefit or protection of School or Program Participants.
7. NON-DISCRIMINATION. There shall be no discrimination on the basis of race, national origin, religion,
creed, sex, age, veteran status, or handicap in either the selection of Participating Students, or as to any
aspect of the Clinical Program; provided, however, that with respect to handicap, the handicap must not be
such as would, even with reasonable accommodation, in and of itself preclude the Program Participant's
effective participation in the Clinical Program.
8. INDEMNIFICATION. To the extent permitted by applicable law and without waiving any defenses,
School shall indemnify and hold harmless Hospital and Hospital’s officers, directors, trustees, medical and
nursing staff, representatives and employees from and against all third-party liabilities, claims, damages
and expenses, including reasonable attorneys’ fees, relating to or arising out of any act or omission of
School or any of its Program Participants, agents, representatives or employees in connection with this
Agreement, including, but not limited to, claims for personal injury, professional liability, or with respect to
the failure to make proper payment of required taxes, withholding, employee benefits or statutory or other
entitlements.
9. CONFIDENTIALITY. School will and will ensure that Program Participants keep strictly confidential
and hold in trust all non-public information of Hospital, including all patient information, and refrain from
disclosing such confidential information to any third party without the express prior written consent of
Hospital, provided that the minimum necessary confidential information may be disclosed pursuant to valid
legal process after Hospital is permitted an opportunity to minimize the potential harmful affects of such
disclosure. School shall not disclose the terms of this Agreement to any person who is not a party to this
Agreement, except as required by law or as authorized by Hospital. These confidentiality requirements
survive the termination or expiration of the Agreement. In addition to the requirements set forth in this
Section, Program Participants shall abide by the terms of Exhibit B.
10. TERM; TERMINATION.
(a) The term of this Agreement will commence on the Effective Date and will continue for two (2)
years unless terminated as provided below (the “Term”).
(b) Either Party may terminate this Agreement at any time without cause upon at least sixty (60)
calendar days prior written notice to the other Party, provided that all Participating Students
participating in the Program at the time of notice of termination or who are already scheduled
to train at the Facility shall be given the opportunity to complete the then-current Program
rotation or previously scheduled clinical assignment.
(c) The Parties may terminate this Agreement at any time by mutual written agreement.
(d) Hospital may immediately terminate this Agreement at any time upon notice to School in the
event of a breach of Section 11 of this Agreement.
11. REPRESENTATIONS AND WARRANTIES.
(a) School hereby represents to Hospital as of the Effective Date and warrants to Hospital for the
Term that:
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(i) School and its Program Participants: (A) are not excluded, debarred, or otherwise ineligible
to participate in the Federal health care programs as defined in 42 U.S.C. Section 1320a-
7b(f) (the “Federal health care programs”); (B) are not convicted of a criminal offense
related to the provision of health care items or services but has not yet been excluded,
debarred or otherwise declared ineligible to participate in the Federal health care programs,
and (C) are not under investigation or otherwise aware of any circumstances which may
result in the School, or a Program Participant being excluded from participation in the
Federal health care programs; and
(ii) in the aggregate, School and all of School’s affiliates compensate all physician employees
and physician contractors (if any) (A) in an amount that is consistent with fair market value
for actual services provided, and (B) in a manner that does not vary with or take into
account the volume or value of patient referrals to, or other business generated for,
Hospital or any of Hospital's affiliates. Furthermore, all of School's and its affiliates'
compensation arrangements with physician employees and physician contractors are
memorialized in a signed written agreement or other satisfy an exception to the Stark Law
physician referral prohibitions provided in 42 U.S.C. § 1395nn(a)(1).
(b) The representation and warranty set forth above is an ongoing representation and warranty for
the Term of this Agreement. School will immediately notify Hospital in writing of any change in
status of the representation and warranty set forth in this section.
12. TRAVEL EXPENSES. No expense of School or of a Program Participant will be paid or reimbursed
by Hospital unless that expense is approved by Hospital in writing in advance and is incurred and
documented in accordance with applicable Hospital travel and expense policies.
13. USE OF NAME OR LOGO. School will not, and will cause Program Participants not to use names,
logos or marks associated with Hospital without the express written consent of Hospital in each case.
14. ENTIRE AGREEMENT. This Agreement and its Exhibits set forth the entire Agreement with respect to
the subject matter hereof and supersedes all prior agreements, oral or written, and all other communications
between the Parties relating to such subject matter. This Agreement may not be amended or modified
except by mutual written agreement of the Parties. All continuing covenants, duties and obligations herein
shall survive the expiration or earlier termination of this Agreement.
15. SEVERABILITY. If any provision of this Agreement is held to be invalid or unenforceable for any
reason, this Agreement shall remain in full force and effect in accordance with its terms disregarding such
unenforceable or invalid provision.
16. CAPTIONS. The captions contained herein are used solely for convenience and shall not be deemed
to define or limit the provisions of this Agreement.
17. NO WAIVER. Delay or failure to exercise any right or remedy hereunder will not impair such right or
remedy or be construed as a waiver thereof. Any single or partial exercise of any right or remedy will not
preclude any other or further exercise thereof or the exercise of any other right or remedy.
18. GOVERNING LAW . This Agreement shall be governed and construed in accordance with the laws of
the state where the Facility is located. Venue for all disputes arising in connection with this Agreement will
be in the federal or state courts with jurisdiction for the area where the Facility is located.
19. ASSIGNMENT; BINDING EFFECT. School may not assign or transfer any of its rights, duties or
obligations under this Agreement, in whole or in part, without the prior written consent of Hospital. This
Agreement shall inure to the benefit of, and be binding upon, the Parties and their respective successors
and permitted assigns.
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20. NOTICES. All notices hereunder by either Party to the other shall be in writing, delivered personally,
by certified or registered mail, return receipt requested, or by overnight courier, and shall be deemed to
have been duly given when delivered personally or when deposited in the United States mail, postage
prepaid, addressed as follows:
If to Hospital: Eastern Idaho Regional Medical Center
3100 Channing Way, Idaho Falls, ID 83404
Attention: Chief Executive Officer
Copy to: HCA
One Park Plaza, Bldg. 1, 2-East
Nashville, TN 37203
Attention: Operations Counsel
If to School:
Attention: Associate Dean of Student Affairs
or to such other person or place as either Party may from time to time designate by written notice to the
other Party.
21. COUNTERPARTS. This Agreement may be executed in multiple parts (by facsimile transmission or
otherwise) and each counterpart shall be deemed an original, and all of which together shall constitute but
one agreement. Electronic signatures will be considered originals.
22. HIPAA REQUIREMENTS. To the extent applicable to this Agreement, School agrees to comply with
the Health Information Technology for Economic and Clinical Health Act of 2009 (the “HITECH ACT”), the
Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996,
as codified at 42 USC § 1320d through d-8 (“HIPAA”) and any current and future regulations promulgated
under either the HITECH Act or HIPAA including without limitation the federal privacy regulations contained
in 45 C.F.R. Parts 160 and 164 (the “Federal Privacy Regulations”), the federal security standards
contained in 45 C.F.R. Parts 160, 162 and 164 (the “Federal Security Regulations”) and the federal
standards for electronic transactions, all as may be amended from time to time, and all collectively referred
to herein as “HIPAA Requirements”. School further agrees not to use or disclose any Protected Health
Information (as defined in 45 C.F.R. § 164.501) or Individually Identifiable Health Information (as defined in
42 USC § 1320d), other than as permitted by HIPAA Requirements and the terms of this Agreement.
School will and will cause Program Participants to enter into any further agreements as necessary to
facilitate compliance with HIPAA Requirements.
23. NO REQUIREMENT TO REFER. Nothing in this Agreement requires or obligates School to cause the
admittance of a patient to Hospital or to use Hospital’s services. None of the benefits granted pursuant to
this Agreement are conditioned on any requirement or expectation that the Parties make referrals to, be in
a position to make or influence referrals to, or otherwise generate business for the other Party. Neither
Party is restricted from referring any services to, or otherwise generating any business for, any other entity
of their choosing.
24. NO PAYMENTS. Except as provided in Section 5, no payments will be made between the Parties or
to the Program Participants in connection with this Agreement.
25. RECITALS. The Recitals to this Agreement shall be an enforceable part of this Agreement, binding
on the Parties as if fully set forth herein.
26. EQUITABLE REMEDIES. School acknowledges that the injury which might be suffered by Hospital in
the event of any breach by School or non-compliance by Program Participants with the terms and conditions
EXHIBIT A
STATEMENT OF RESPONSIBILITY
For and in consideration of the benefit provided the undersigned in the form of experience in a clinical
setting at _________________________________________ ("Hospital"), the undersigned and his/her
heirs, successors and/or assigns do hereby covenant and agree to assume all risks and be solely
responsible for any injury or loss sustained by the undersigned while participating in the Program operated
by: ________________________________________ ("School") at Hospital unless such injury or loss
arises solely out of Hospital's gross negligence or willful misconduct.
Signature of Program Participant/Print Name Date
Parent or Legal Guardian Date
If Program Participant is under 18 / Print Name
EXHIBIT B
Confidentiality and Security Agreement
I understand that the Hospital or business entity (the “Hospital”) for which I work, volunteer or provide
services manages health information as part of its mission to treat patients. Further, I understand that the
Hospital has a legal and ethical responsibility to safeguard the privacy of all patients and to protect the
confidentiality of their patients’ health information. Additionally, the Hospital must assure the
confidentiality of its human resources, payroll, fiscal, research, internal reporting, strategic planning
information, or any information that contains Social Security numbers, health insurance claim numbers,
passwords, PINs, encryption keys, credit card or other financial account numbers (collectively, with
patient identifiable health information, “Confidential Information”).
In the course of my employment/assignment at the Hospital, I understand that I may come into
the possession of this type of Confidential Information. I will access and use this information only when it
is necessary to perform my job related duties in accordance with the Hospital’s Privacy and Security
Policies, which are available on the Hospital intranet (on the Security Page) and the Internet (under Ethics
& Compliance). I further understand that I must sign and comply with this Agreement in order to obtain
authorization for access to Confidential Information or Hospital systems.
General Rules:
1. I will act in the best interest of the Hospital and in accordance with its Code of Conduct at all
times during my relationship with the Hospital.
2. I understand that I should have no expectation of privacy when using Hospital information
systems. The Hospital may log, access, review, and otherwise utilize information stored on
or passing through its systems, including email, in order to manage systems and enforce
security.
3. I understand that violation of this Agreement may result in disciplinary action, up to and
including termination of employment, suspension, and loss of privileges, and/or termination
of authorization to work within the Hospital, in accordance with the Hospital’s policies.
Protecting Confidential Information:
1. I understand that any Confidential Information, regardless of medium (paper, verbal,
electronic, image or any other), is not to be disclosed or discussed with anyone outside
those supervising, sponsoring or directly related to the learning activity.
2. I will not disclose or discuss any Confidential Information with others, including friends or
family, who do not have a need to know it. I will not take media or documents containing
Confidential Information home with me unless specifically authorized to do so as part of my
job. Case presentation material will be used in accordance with Hospital policies.
3. I will not publish or disclose any Confidential Information to others using personal email, or to
any Internet sites, or through Internet blogs or sites such as Facebook or Twitter. I will only
use such communication methods when explicitly authorized to do so in support of Hospital
business and within the permitted uses of Confidential Information as governed by
regulations such as HIPAA.
4. I will not in any way divulge, copy, release, sell, loan, alter, or destroy any Confidential
Information except as properly authorized. I will only reuse or destroy media in accordance
with Hospital Information Security Standards and Hospital record retention policy.
5. In the course of treating patients, I may need to orally communicate health information to or
about patients. While I understand that my first priority is treating patients, I will take
reasonable safeguards to protect conversations from unauthorized listeners. Whether at the
School or at the Hospital, such safeguards include, but are not limited to: lowering my voice
or using private rooms or areas (not hallways, cafeterias or elevators) where available.
6. I will not make any unauthorized transmissions, inquiries, modifications, or purgings of
Confidential Information. I will not access data on patients for whom I have no
responsibilities or a need-to-know the content of the PHI concerning those patients.
7. I will not transmit Confidential Information outside the Hospital network unless I am
specifically authorized to do so as part of my job responsibilities. If I do transmit Confidential
Information outside of the Hospital using email or other electronic communication methods, I
will ensure that the Information is encrypted according to Hospital Information Security
Standards.
Following Appropriate Access:
1. I will only access or use systems or devices I am officially authorized to access, and will not
demonstrate the operation or function of systems or devices to unauthorized individuals.
2. I will only access software systems to review patient records or Hospital information when I
have a business need to know, as well as any necessary consent. By accessing a patient’s
record or Hospital information, I am affirmatively representing to the Hospital at the time of
each access that I have the requisite business need to know and appropriate consent, and
the Hospital may rely on that representation in granting such access to me.
Using Portable Devices and Removable Media:
1. I will not copy or store Confidential Information on removable media or portable devices such
as laptops, personal digital assistants (PDAs), cell phones, CDs, thumb drives, external hard
drives, etc., unless specifically required to do so by my job. If I do copy or store Confidential
Information on removable media, I will encrypt the information while it is on the media
according to Hospital Information Security Standards
2. I understand that any mobile device (Smart phone, PDA, etc.) that synchronizes Hospital
data (e.g., Hospital email) may contain Confidential Information and as a result, must be
protected. Because of this, I understand and agree that the Hospital has the right to:
a. Require the use of only encryption capable devices.
b. Prohibit data synchronization to devices that are not encryption capable or do not
support the required security controls.
c. Implement encryption and apply other necessary security controls (such as an
access PIN and automatic locking) on any mobile device that synchronizes Hospital
data regardless of it being a Hospital or personally owned device.
d. Remotely "wipe" any synchronized device that: has been lost, stolen or belongs to a
terminated employee or affiliated partner.
e. Restrict access to any mobile application that poses a security risk to the Hospital
network.
Doing My Part – Personal Security:
1. I understand that I will be assigned a unique identifier (e.g., 3-4 User ID) to track my access
and use of Confidential Information and that the identifier is associated with my personal
data provided as part of the initial and/or periodic credentialing and/or employment
verification processes.
2. I will:
a. Use only my officially assigned User-ID and password (and/or token (e.g., SecurID
card)).
b. Use only approved licensed software.
c. Use a device with virus protection software.
3. I will never:
a. Disclose passwords, PINs, or access codes.
b. Use tools or techniques to break/exploit security measures.
c. Connect unauthorized systems or devices to the Hospital network.
4. I will practice good workstation security measures such as locking up diskettes when not in
use, using screen savers with activated passwords, positioning screens away from public
view.
5. I will immediately notify my manager, Hospital Information Security Official (FISO), Director
of Information Security Operations (DISO), or Hospital or Corporate Client Support Services
(CSS) help desk if:
a. my password has been seen, disclosed, or otherwise compromised;
b. media with Confidential Information stored on it has been lost or stolen;
c. I suspect a virus infection on any system;
d. I am aware of any activity that violates this agreement, privacy and security policies;
or
e. I am aware of any other incident that could possibly have any adverse impact on
Confidential Information or Hospital systems.
Upon Termination:
1. I agree that my obligations under this Agreement will continue after termination of my
employment, expiration of my contract, or my relationship ceases with the Hospital.
2. Upon termination, I will immediately return any documents or media containing Confidential
Information to the Hospital.
3. I understand that I have no right to any ownership interest in any Confidential Information
accessed or created by me during and in the scope of my relationship with the Hospital.
By signing this document, I acknowledge that I have read this Agreement and I agree to comply with all
the terms and conditions stated above.
Signature Hospital Name and
COID
Date
Printed Name Business Entity Name
EXHIBIT C
Attestation of Satisfactory Background Investigation
On behalf of _______________________ [Name of Volunteer Organization, School, Contract Services
Entity, or Staffing Agency], I acknowledge and attest to __________________ [Name of facility] (“Hospital”)
that we own, and have in our possession, a background investigation report on the individual identified
below. Such background investigation is satisfactory in that it:
____ does not reveal any criminal activity;
____ does not reveal ineligibility for rehire with any former employer or otherwise indicate poor
performance;
____ confirms the individual is not on either the GSA or OIG exclusion lists;
____ confirms the individual is not listed as a violent sexual offender;
____ confirms this individual is not on the U.S. Treasury Department’s Office of Foreign Assets Control list
of Specially Designation Nationals;
____ no other aspect of the investigation required by Employer reveals information of concern; and
I further attest there are no prior or pending investigations, reviews, sanctions or peer review proceedings;
or limitations of any licensure, certification or registration.
This attestation is provided in lieu of providing a copy of the background investigation.
Identified Individual Subject to the Background Investigation:
Name:
Address:
Date of Birth:
Social Security Number:
I also acknowledge and agree to an annual compliance audit by Hospital of five percent (5%) or a minimum
of thirty (30) such background investigation files as authorized by the subjects under the Fair Credit
Reporting Act (FCRA).
Signature
Printed Name
[Name of Organization]
Date: