AFFILIATION AGREEMENT WITH GULF COAST DIETETIC INTERNSHIP.PDF

Gulf Coast Dietetic Internship
Affiliation Agreement
This Affiliation Agreement (“Agreement”) is entered into between The Gulf Coast Dietetic Internship
Program (“GCDI”) located at 724 Live Oak Drive, Biloxi, MS 39532 and Maricopa County administered by
its Human Services Department Head Start Program (“Affiliated Facility”), located at 2150 S. Country
Club Dr. Mesa AZ 85210. GCDI and Affiliated facility shall be collectively referred to as “Parties” and
individually as “Party.”
PURPOSE
GCDI and Affiliated facility seek to provide supervised practice educational experiences for Dietetic
Interns (“Interns”) enrolled in the Dietetic Internship Program at GCDI. This Agreement will establish a
cooperative relationship between Parties and outline the responsibilities of the Parties as they
contribute to the learning experience of Interns who benefit from, and participate in, the Dietetic
Internship Program at GCDI in a safe and responsible manner.
TERMS
THEREFORE, in consideration of the mutual promises and agreements contained in this Agreement,
Parties agree as follows:
ARTICLE 1 - JOINT RESPONSIBILITIES OF THE PARTIES
a. The performance experiences will cover a period of time agreed on and arranged by GCDI faculty
supervising the Dietetic Internship and preceptors in the Affiliated Facility. The beginning date and
length of experience shall be mutually agreed upon prior to the beginning of the affiliation.
b. Without limitation of any provision set forth in this Agreement, Parties expressly agree to abide by
all applicable federal and/or state equal employment opportunity statutes, rules, and regulations;
c. GCDI faculty and the staff of the Affiliated Facility agree to establish performance objectives and
experiences, devise methods for their implementation, and determine the effectiveness of these
experiences by ongoing methods of evaluation.
d. GCDI faculty and the staff of the Affiliated Facility agree to maintain communication, cooperate in
the development of educational experiences for the Dietetic Internship and review and evaluate the
rules and the regulations necessary for the success of the program in the Affiliated Facility upon
request.
e. The Affiliated Facility agrees to indemnify and hold harmless GCDI, the Board, its officers, agents and
employees for any damages including claims, demands, losses, and costs occurring during the course
of a required placement in the clinical experience arising out of the negligent acts or omission of the
Affiliated Facility or any of its agents, officers, or employees.
f. GCDI agrees to indemnify and hold harmless the Affiliated Facility for any damages, losses, claims or
demands arising out of the negligent acts or omissions of the GCDI employees, officers, or agents.
g. Interns are not employees of either GCDI or the Affiliated Facility and are not entitled to any
employee benefits or compensation from Parties which includes not providing Worker’s
Compensation coverage.
Page 1 of 4
Rev: Dec 18, 2018

Gulf Coast Dietetic Internship
h. Parties will instruct their respective faculty, staff, and Interns to maintain confidentiality of student
and patient information as required by law, including the Family Educational Rights and Privacy Act
(FERPA), and the Health Insurance Portability Accountability Act (HIPAA) and by policies and
procedures of GCDI and the Affiliated Facility.
i. In accordance with HIPAA regulations, Interns are considered part of the Affiliated Facility’s
workforce as defined in 45 CFR §160.103 because Interns are trainees under the direct control of
the facility even though they are not compensated nor employees of the Affiliated Facility.
Therefore, Interns are subject to the Affiliated Facility’s policy and procedure regarding
confidentiality of patient records and HIPAA Regulations. Interns shall be instructed by Affiliated
Facility before beginning the Internship concerning the confidentiality of medical information of
Affiliated Facility’s participants and standard precautions. For purposes of compliance with HIPAA,
Interns are not considered work force or employees of Affiliated Facility for any other purposes,
including by and not limited to tax or employment law.
j. It is agreed that GCDI is not a “Business Associate” of the Affiliated Facility as that term is defined by
HIPAA and its accompanying regulations. Neither GCDI nor the Intern is engaged in performing or
assisting the Affiliated Facility in performing any of the Business Associate functions that are listed in
the HIPAA Regulations, 45 CFR §160.103. The GCDI Program is considered part of “health care
operations” under HIPAA Regulations, 45 CFR §164.501.
k. In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA), the Affiliated
Facility shall ensure Intern’s educational records are kept confidential under FERPA and state law.
l. The Affiliated Facility may immediately remove any Intern participating in the Internship from the
Affiliated Facility’s premises for behavior that the Affiliated Facility deems to be an immediate threat
to the health or welfare of the Affiliated Facility’s patients, staff members, and visitors or to the
Affiliated Facilities operations. The Affiliated Facility shall notify GCDI in writing of its actions and the
reasons for its actions as soon as practicable. If the Affiliated Facility desires to remove an Intern for
any other reason, Affiliated Facility shall notify GCDI in writing of the reasons for the removal and
shall consult with the GCDI before removing the Intern.
ARTICLE 2. RESPONSIBILITIES OF GCDI
a. Each Intern must comply with the rules and regulations that are applicable to the Intern’s
performance in the Affiliated Facility. These would include:
i. Following the administrative policies, standards, and practices and regulations, including dress
code, of the Affiliated Facility;
ii. Providing Intern’s own transportation and living arrangements while attending the Affiliated
Facility;
iii. Providing Intern’s own health and accident insurance and provide documentation of such
coverages to the Affiliated Facility upon request; and,
iv. Providing documentation of any health screening reports, immunizations, criminal background
checks, liability insurance coverage or similar documentation as requested by the Affiliated
Facility.
Page 2 of 4
Rev: Dec 18, 2018

Gulf Coast Dietetic Internship
b. GCDI will procure and maintain professional liability insurance coverage in the amounts of $1 million
individual and $3 million aggregate using an “A” rated company.
c. The GCDI faculty will supply the Affiliated Facility to prepare appropriate forms or arrange
conferences that will be used in evaluating the performance of the assigned Intern.
d. GCDI faculty will only assign Interns to the Affiliated Facility who have satisfactorily completed the
designated prerequisites as determined by the curriculum.
ARTICLE 3 - RESPONSIBILITIES OF THE AFFILIATED FACILITY
a. Provide necessary instruction for prescribed supervised practice experiences for Interns, as agreed
upon by both Parties, including but not limited to preceptors to supervise practice instruction for
Students during experiential rotations at the Affiliated Facility.
b. Where appropriate, provide qualified supervisory personnel to work in conjunction with CGDI
faculty;
c. Provide GCDI’s designee with a performance appraisal for each Student in the form prescribed by
GCDI;
d. Report any unsatisfactory conduct or performance of an Intern in a form prescribed by GCDI;
e. Permit designated GCDI faculty members the right to counsel with and to observe Interns at
Affiliated Facility;
f. Provide initial emergency care at the Intern’s expense in case of accidents to Interns participating in
regularly scheduled duty periods.
ARTICLE 4 - EFFECTIVE DATE, TERMINATION AND MODIFICATION
a. This Agreement shall be effective January 30, 2019 – January 30, 2020 and automatically renewed
for one (1) year terms unless otherwise terminated by any Party.
b. This Agreement may only be modified by unanimous, written agreement signed by authorized
signers for Parties.
c. Any Party may terminate this Agreement for any reason after providing ninety (90) days' written
notice to the authorized person for other Party. Notice shall be sent by registered mail. Any Party
may terminate this Agreement after the terminating Party has provided the other Party thirty (30)
days to cure the alleged deficiency.
d. This Agreement is subject to A.R.S. § 38-511, the pertinent provisions of which are incorporated
here by reference. Cancellation under this section shall be effective when written notice from the
terminating Party is received by the other Party unless the notice specifies a later time.
e. Any Intern currently placed with an Affiliated Facility shall be permitted to complete the placement
unless the Intern is personally responsible for the reason termination is requested. If the Intern is
the reason for the requested termination, the Intern’s participation in the program shall
immediately cease.
ARTICLE 5 - GENERAL PROVISIONS
Page 3 of 4
Rev: Dec 18, 2018

Gulf Coast Dietetic Internship
a. Agreement shall be governed by, and construed in accordance with, the laws of the state of Arizona,
which shall be the forum for any lawsuits arising from, and incident to, this Agreement.
b. Nothing in the Agreement is to be construed as transferring financial responsibility from one party
to another.
c. This Agreement is entered into by and between Parties hereto and for their benefit. Unless explicitly
provided in this Agreement, there is no intent by either Party to create or establish third Party
beneficiary status or rights in any third party, and no such third party shall have any right to enforce
any right or enjoy any benefit created or established under this Agreement.
d. Unless expressly provided herein, Parties do not assume or become liable for any of the existing or
future obligations, liabilities, or debt of the other.
e. This is the entire Agreement between Parties and supersedes all prior agreements, proposals, or
understandings, whether written or oral.
The contact persons for any notices required by this Affiliation Agreement are as follows:
For GCDI: Gina Wack Ph: 228-297-8446
For AFFILIATED FACILITY: Chrisanda DeBois Ph: 602-372-3700, Ext. 23716
IN WITNESS WHEREOF, the authorized representatives of GCDI and the Affiliated Facility have caused
this Agreement to be executed on the date listed with the representatives’ signatures.
For Affiliated Facility:
Signature: Date:
Name: Title: Chairman Board Of Supervisors
Attested to:
Signature: Date:
Name: Fran McCarroll Title: Clerk of the Board
Approved as to form:
Signature: Date:
Name: Title: Deputy County Attorney
For Gulf Coast Dietetic Internship:
Signature: Date:
Name: Gina Wack Title: Director, Gulf Coast Dietetic Internship
Page 4 of 4
Rev: Dec 18, 2018