IASTATE STUDENT AGREEMENT 2.DOCX

Affiliation Agreement
Nationwide-Option Dietetic Internship
Food Science and Human Nutrition Department
College of Human Sciences and College of Agriculture and Life Sciences
220 C MacKay Hall
Iowa State University
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 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 learning experiences and facilities for ISU Interns enrolled in its Dietetic Internship Program.
This Affiliation Agreement will establish a cooperative relationship between ISU 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 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 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. ISU faculty and the staff of the Affiliated Facility agree to maintain communications, 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 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.
f. To the extent permitted by law under the Iowa Tort Claims Act, Iowa Code Chapter 669,
(http://www.legis.state.ia.us/IACODE/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.
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g. Interns 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 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.
i. If the Affiliated Facility is a HIPAA Covered Entity pursuant to HIPAA regulations, the ISU
Dietetic 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 and therefore Interns 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.
j. 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 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 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 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
assignment to the facility. The Intern’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
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 from direct patient/client/employee access.
c. Dietetic Internship faculty will require the assigned Interns to comply with the rules and
regulations which are applicable to her/his 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 his or her own transportation and living arrangements while attending the
Affiliated Facility.
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iii. 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 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 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.
e. ISU Dietetic Internship faculty will assign only Interns 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 with an orientation that includes:
a copy of the pertinent rules and regulations with which the Intern is expected to comply, a tour
of the facilities where the Intern will be learning, the philosophy of patient care at the Affiliated
Facility, and other topics that will allow the Intern a quality learning experience during the
internship to the benefit of the Affiliated Facility, ISU and the Intern.
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
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 and agrees to adhere to the Internship policy that "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 experience and maintain
complete records pertaining to each Intern’s performance. Written evaluations will be provided
to the Dietetic Internship faculty using the forms described in Section IIe of this Agreement.
e. Preceptors in the Affiliated Facility will be provided with time to plan, implement, and evaluate
the Intern experiences and, when feasible, attend relevant conferences with or about Interns.
f. In the event of an emergency, or other health care or medical needs, the Intern 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.
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g. Upon reasonable request by ISU, the Affiliated Facility will permit the inspection of the facilities,
services available for learning experiences, Intern’s records, and such other items pertaining to
the Dietetic Internship Program.
IV. EFFECTIVE DATE, MODIFICATION, AND TERMINATION
a. This agreement shall be effective on July 1, 2013 through June 30, 2018 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 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.
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.
d. 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: Jean A. Anderson (515) 294-7316
For AFFILIATED FACILITY: Strategic Planning & Operations Supervisor (602) 506-6606
WIC Program Educator (602) 506-9318
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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:
Chairman, Date
Maricopa County Board of Supervisors Name: Jean Anderson, M.S., R.D., L.D.
Title: Director, Dietetic Internship
Attest:
By:
Clerk of the Board Date Date
Name: Ruth MacDonald, PhD, R.D.
Title: Food Science & Human Nutrition
Department Chair
Director, MCDPH Date
Approved as to Form Date
Deputy County Attorney
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