AFFILIATE AGRMT FOR PH STUDENT TRNG WITH IOWA STATE UNV.PDF

Affiliation Agreement
Dietetic Internship
Kinesiology and Health Student Rotations
Food Science and Human Nutrition Department
Kinesidogy Department
College of Human Sciences and College of Agriculture and Life Sciences
220 MacKay
Iowa State University of Science and Technology
Ames, IA 50011-1123
and
Maricopa County
Acting for and on behalf of its
Department of Public Health
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AFFILIATION AGREEMENT
This Affiliation Agreement is entered into between the Dietetic Internship and the Kinesiology Department
located at Iowa State University of Science and Technology ("ISU"), within its Colleges of Human Sciences and
of Agriculture and Life Sciences, and the Department of Food Science and Human Nutrition, located at Ames,
IA, and Maricopa County, acting for and on behalf of its Department of Public Health ("Affiliated Facility") with
its principal office located at 4041 N. Central Ave., Suite 1400, Phoenix, Arizona 85012.
PURPOSE
The purpose of this Affiliation Agreement is to form an agreement with a facility that is committed to providing
desirable dietetics and kinesiology and health learning experiences and facilities for ISU Interns and Students
enrolled in its Dietetic Internship Program and Kinesiology Department. This Affiliation Agreement will establish
a cooperative relationship between 1SU and the Affiliated Facility and outline the responsibilities of the
cooperating parties as they contribute to the learning experience of Interns who benefit from, and participate in,
the ISU Dietetic Internship Program and Kinesiology Department in a safe and responsible manner.
TERMS
THEREFORE, in consideration of the mutual promises and agreements contained in this Affiliation Agreement,
ISU and the Affiliated Facility agree as follows:
I JOINT RESPONSIBILITIES
a. The performance experiences will cover a period of time agreed on and arranged by ISU faculty
supervising the Dietetic Internship and/or Kinesiology and Health rotations 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. Both parties agree that there shall be no discrimination on the basis of marital status, race,
color, ethnicity, sex, age, religion, pregnancy, sexual orientation, gender identity, genetic
information, disability, national origin or status as a U.S. Veteran pertaining to any experiences
during the Dietetic Internship.
c. ISU 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. 1SU faculty and the staff of the Affiliated Facility agree to maintain communications, cooperate in
the development of educational experiences for the Dietetic Internship and Kinesiology and
Health Department 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 Iowa State University, the Board of
Regents, State of Iowa, 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.
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f. To the extent permitted by law under the Iowa Tort Claims Act, Iowa Code Chapter 669,
(http://www.legis.state.ia.us/lACODE/Current/), Iowa State University 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 Iowa State University employees, officers, or agents,
g. Interns and Students are not employees of either Iowa State University or the Affiliated Facility
and are not entitled to any stipends, benefits, conditions, terms or rights of Iowa State University
or Affiliated Facility employees including any defense or indemnity under Maricopa County's
Declaration of Trust for Maricopa County, Arizona, Self-Insured Risk Trust Fund, worker's
compensation, medical or hospitalization insurance or benefits, pension, retirement or vacation
pay, credit or other benefits or rights of Iowa State University or Affiliated Facility employees.
h. Both parties will instruct their respective faculty, staff, and participating Interns and Students 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 ISU and the Affiliated Facility.
If the Affiliated Facility is a HIPAA Covered Entity pursuant to HIPAA regulations, the 1SU
Dietetic Interns and Kinesiology and Health students are considered part of the Affiliated
Facility's workforce as defined in 45 CFR 160.103 because Interns and Students are trainees
under the direct control of the facility even though they are not compensated nor employees of
the Affiliated Facility and therefore Interns and Students are subject to the Affiliated Facility's
policy and procedure including Confidentiality of patient records and HIPAA Regulations and it
is the responsibility of the Affiliated Facility to train the intern on its specific policy and
procedure.
If the Affiliated Facility is a HIPAA Covered Entity, it is agreed that ISU is not a "Business
Associate" of the Affiliated Facility as that term is defined by HIPAA and its accompanying
regulations. Neither ISU nor the Intern or Student 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 ISU Dietetic Internship Program and Kinesiology
and Health Department is considered part of 'health care operations" under HIPAA Regulations,
45 CFR §164,501.
k. Either party may require the immediate withdrawal of any Intern or Student from the clinical area
whose conduct has a detrimental effect on patients or personnel of the Affiliated Facility.
II. RESPONSIBILITIES OF THE ISU FACULTY
a. ISU faculty will notify the supervisors in an Affiliated Facility of the planned schedule of Intern
and Student assignment to the facility. The Intern's/Student's name, previous academic
preparation, and length and dates of the planned experience will be provided to the facility
before the experience begins.
b. ISU faculty will make a reasonable effort to initiate a criminal background check of the Intern or
Student assigned to the Affiliated Facility. The result of the criminal background check may be
obtained by the Affiliated Facility upon request. If any information is uncovered that would
indicate a record of abuse or neglect or a felony conviction, ISU faculty shall notify the Affiliated
Facility and decisions may be made that prevent the Intern or Student from direct
patient/client/emplayee access.
c. Dietetic Internship and Kinesiology and Health faculty will require the assigned Interns or
Students to comply with the rules and regulations which are applicable to her/his performance in
the Affiliated Facility. These would include:
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i. Following the administrative policies, standards, and practices and regulations,
including dress code, of the Affiliated Facility.
Providing his or her own transportation and living arrangements while attending the
Affiliated Facility.
Providing his or her own health and accident insurance and providing documentation of
such coverages to the Affiliated Facility upon request.
iv. Providing documentation of any health screening reports, immunizations, criminal
background checks, liability insurance coverage or similar documentation as requested
by the Affiliated Facility.
d. The ISU Dietetic Internship or Kinesiology and Health Department will provide professional and
either general liability insurance coverage or self-insurance coverage to each individual rotating
Intern for the duration of the assigned rotation. Such coverage shall include both liability
protection and the costs of any and all claims, demands, losses, expenses, causes of action or
litigation, and include "nose or tail coverage" for any "claims made" until any applicable statute
of limitations expires. Such insurance coverage shall include at a minimum $1,000,000 per
occurrence and $3,000,000 annual aggregate. ISU will provide proof of such coverage to the
Affiliated Facility upon request.
e. The Dietetic Internship or Kinesiology and Health faculty will supply or work with the Affiliated
Facility to prepare appropriate forms or arrange conferences that will be used in evaluating the
performance of the assigned Intern or Student.
f. ISU Dietetic Internship or Kinesiology and Health faculty will assign only Interns and Students to
the Affiliated Facility who have satisfactorily completed the designated prerequisites as
determined by the curriculum.
III. RESPONSIBILITIES OF THE AFFILIATED FACILITY
a. The Affiliated Facility shall provide the Dietetic Internship Intern or Kinesiology and Health
Student with an orientation that includes: a copy of the pertinent rules and regulations with
which the Intern or Student is expected to comply, a tour of the facilities where the Intern or
Student will be learning, the philosophy of patient care at the Affiliated Facility, and other topics
that will allow the Intern or Student a quality learning experience during the internship/rotation to
the benefit of the Affiliated Facility, ISU and the Intern or Student.
b. The Affiliated Facility shall maintain full administrative and supervisory responsibility for the
quality of care given patients and maintain administrative responsibility in so far as a
Intern's/Student's presence affects the operation of the Affiliated Facility and/or direct or indirect
care of patients/clients/employees.
c. The Affiliated Facility shall provide observational opportunities and practical experiences to
benefit the learning of Intern or Student and agrees that "interns or Students in supervised
practice programs shall not routinely replace employees except for planned professional staff,
experiences."
d. The Affiliated Facility shall provide a supervised program of dietetics or Kinesiology and Health
experience and maintain complete records pertaining to each Intern's/Student's performance.
Written evaluations will be provided to the Dietetic Internship or Kinesiology and Health faculty
using the forms described in Section II.f. of this Agreement.
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e. Preceptors in the Affiliated Facility will be provided with time to plan, implement, and evaluate
the Intern or Student experiences and, when feasible, attend relevant conferences with or about
Interns/Students.
f. In the event of an emergency, or other health care or medical needs, the Intern or Student may
be treated in the Affiliated Facility by qualified staff. If necessary, arrangements for
transportation to another medical facility will be made. The cost of transportation and all
medical treatment will be borne by the Intern or Student.
g. Upon reasonable request by ISU, the Affiliated Facility will permit the inspection of the facilities,
services available for learning experiences, Intern's/Student's records, and such other items
pertaining to the Dietetic Internship Program or Kinesiology and Health Department.
IV. EFFECTIVE DATE, MODIFICATION, AND TERMINATION
a. This agreement shall be effective on January 1, 2016 through June 30, 2020 unless otherwise
terminated by one of the parties.
b. This agreement may be revised or modified by written amendment when both parties agree to
such amendment.
c. This Affiliation Agreement will be terminated 90 days after a written notice to the below named
person by registered mail from either party. This agreement may also be terminated by either
party for cause after providing the other party 30 days to cure the deficiency in performance
under this Affiliation Agreement. Any Intern or Student currently placed with an Affiliated Facility
shall be permitted to complete the placement unless the Intern or Student is personally
responsible for the reason termination is requested.
V. MISCELLANEOUS PROVISIONS
a. Nothing contained herein shall be deemed or construed as creating a relationship of principal
and agent or of partnership or of joint venture between the Parties.
b. This Agreement shall be binding upon and shall inure to the benefit of both Parties and their
respective successors, heirs, assigns and legal representatives. Neither this Agreement nor
any rights hereunder may be assigned without the prior written consent of the non-assigning
Party.
c. Individuals executing this Agreement on behalf of the Parties represent and warrant that they
have been authorized to do so.
This Agreement contains the entire understanding of the Parties relating to the subject matter of
this Agreement. Any prior agreements, promises, negotiations or representations between the
Parties, either oral or written, relating to the subject matter of this Agreement which are not
expressly set forth herein are of no force or effect. Any modifications or amendments must be
agreed to by both Parties in writing and shall become effective on the date stated therein.
e. The contact persons for any notices required by this Affiliation Agreement are as follows:
For ISU Dietetic Internship Program: Jean A. Anderson (515) 294-7316
For ISU Kinesiology and Health Department: Debra L. Power (515) 294-7412
For AFFILIATED FACILITY: Strategic Planning & Operations Supervisor (602) 506-6606
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IN WITNESS WHEREOF, the authorized representatives of ISU and the Affiliated Facility have caused
this Affiliation Agreement to be executed on the date listed with the representative's signature.
MARICOPA COUNTY IOWA STATE UNIVERSITY
Acting for and on behalf of DIETETIC INTERNSHIP
the Department of Public Health
By: By: (*P4/ / /AA
Chairman, Date
Maricopa County Board of Supervisors Name: Pamela J. White, PhD
Title: Dean, College of Human Sciences
Attest:
Clerk of the Board Date
Date
Approved as to Form Date
Deputy County Attorney
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