PIMA.PDF

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~____] PIMA
J MEDICAL
AFFILIATION AGREEMENT
~~] INSTITUTE
U
This affiliation agreement is entered into between PIMA MEDICAL INSTITUTE, hereinafter referred to as
THE EDUCATIONAL INSTITUTION, and
Name
Address
City & State
hereinafier referred to as THE FACILITY.
THE FACILITY provides medical services and is willing to affiliate with THE EDUCATIONAL
INSTITUTION to conduct an externship program on the terms and conditions set forth herein.
EDUCATIONAL INSTITUTION FACILITY
Campus Director Date _—_ Signature/Title Date
Career Services Coordinator or Date —_ Signature/Title Date
Program Director
CONTACT PERSON
Educational Institution Contact Person Facility Contact Person
Telephone Number Telephone Number
EF.O1 Revised: 02/2016

DUTIES OF THE EDUCATIONAL INSTITUTION:
The EDUCATIONAL INSTITUTION agrees to:
1. Plan the educational program in the FACILITY, including programming, administration,
matriculation, promotion and graduation.
Maintain records and reports of the student's externship experience for a period of at least
three (3) years.
Notify the FACILITY in advance of the planned externship of: student name, program of
study, externship begin date, contact information for the EDUCATIONAL INSTITUTION’s
Career Services Advisor, the FACILITY’s hours of operation, and the total number of
externship hours required. A proposed student work schedule will require approval by the
FACILITY, which shall not be unreasonably withheld.
Use all reasonable effort to facilitate compliance by an assigned student with the rules and
regulations of the FACILITY, including preservation of the confidential nature of information
of the patients and their records.
Provide a copy of the performance objectives for the externship experience and endeavor
to assure that the student is prepared for meeting those objectives.
Provide the necessary paperwork for the FACILITY’S evaluation of the student's
performance while on externship.
indemnify and hold harmless, to the extent of its professional liability insurance, the
FACILITY from all claims, losses, liabilities, costs and expenses, including attorney's fees,
arising in whole or in part from any alleged act or omission of an assigned student,
instructor, employee or any other representative of the EDUCATIONAL INSTITUTION.
Provide evidence of liability insurance coverage or of financial responsibility acceptable to
the FACILITY, as assurance of its accountability for any such losses, claims, liabilities or
expenses.
Provide evidence of student professional liability coverage, in an amount not less than
$1,000,000 per occurrence, $3,000,000 aggregate.
10. Provide documentation confirming assigned students having received the Hepatitis B
vaccination series or, alternatively, documentation confirming student's declination of the
Hepatitis B vaccination series.
DUTIES OF THE FACILITY:
The Facility:
11. Shall retain the right, in its sole discretion, to exclude any individual at any time from the
externship area. The EDUCATIONAL INSTITUTION shall be notified of any such
occurrence.
12. Has the right to terminate any student from the externship program upon giving notice to
the EDUCATIONAL INSTITUTION for reasonable cause, including without limitation, any
situation which may adversely affect patient care.
Pima Medical Institute Page 2 of 3 Revised: 02/2016

13. Will make available, at no charge, the externship area and the practical instruction for the
externship experience. Students will not replace staff or give services to patients aside
from its educational value.
14, Will endeavor to assure that the educational experience provided by the FACILITY shall
be of such quality as to provide the student with a sound externship experience and will
reinforce professionalism.
15, Shall have the right to a copy of the assigned student’s references or transcripts upon
written authorization of the student. It is understood and agreed that this information shall
not be provided to a third party by the FACILITY without further written authorization by the
student. (Family Education Rights and Privacy Act of 1974 (FERPA)).
TERM AND TERMINATION:
This agreement shall be for the term set forth below.
16. This AFFILIATION AGREEMENT shall be reviewed annually and will remain in effect until
terminated by either party upon ninety days (90) days prior written notice, either by
personal service or by certified or registered mail upon the Campus Director of the
EDUCATIONAL INSTITUTION and the representative signing this Agreement on behalf of
the FACILITY, as designated above.
17. Any students enrolled in the ongoing programs at the time of any such termination shail be
given the opportunity by the FACILITY and the EDUCATIONAL INSTITUTION to complete
the requirements of the program as offered at the time of their entry and in compliance with
the conditions contained in this AFFILIATION AGREEMENT.
MISCELLANEOUS:
18. All participants in the EDUCATIONAL INSTITUTION programs agree to abide by existing
rules and any rules or regulations implemented by the FACILITY during their externship.
19. Neither the EDUCATIONAL INSTITUTION nor the FACILITY will discriminate against any
person because of race, color, religion, sex or national origin.
20. This AFFILIATION AGREEMENT shall be subject to review, as the need may arise, in
order to consider any amendment, alteration or change, as may be mutually agreed upon
in writing by the EDUCATIONAL INSTITUTION and the FACILITY.
21. This Agreement contains the entire understanding of the parties and supersedes any prior
understandings and agreements, written or oral.
Pima Medical Institute Page 3 of 3 Revised: 02/2016