MAR-330514 MARICOPA(HOST)_ANATOMICCLINICALPATHOLOGY(HOME)_2024 FINAL.DOCX

PROGRAM LETTER OF AGREEMENT
This Program Letter of Agreement (“Agreement”) shall be effective as of the last date 
signed below. The parties to this Agreement are MAYO CLINIC ARIZONA, with an address 
of 13400 East Shea Boulevard, Scottsdale, AZ 85259, through the Anatomic and Clinical 
Pathology Program of its MAYO CLINIC SCHOOL OF GRADUATE MEDICAL 
EDUCATION (“Mayo Clinic”) and MARICOPA COUNTY, with an address of 301 W 
Jefferson St Suite 170, Phoenix, AZ 85003, through the Office of the Medical Examiner 
(“Clinical Facility”).
WHEREAS, Mayo Clinic sponsors a graduate medical education program in Anatomic 
and Clinical Pathology (“Program”); and
WHEREAS, Clinical Facility desires to provide clinical experiences for respective 
residents and fellows (hereinafter “Resident” or “Residents”); and
WHEREAS, Mayo Clinic and Clinical Facility believe their respective programs will be 
enhanced by Mayo Clinic Residents rotating through Clinical Facility’s clinical site(s).
NOW, THEREFORE, Mayo Clinic and Clinical Facility agree as follows:
1.
Resident Training.
(a)  Clinical Facility shall arrange for a one-month rotation for Mayo Clinic 
Anatomic and Clinical Pathology Residents to obtain forensic/medical examiner experience at its 
clinical site(s).  The rotation will be in compliance with the work hour requirements of the 
Accreditation Council for Graduate Medical Education (“ACGME”).  Educational goals and 
objectives are attached and incorporated herein as Attachment 1.
(b)  Clinical Facility shall provide the clinical facilities and equipment reasonably 
necessary for the Residents’ clinical experiences and allow reasonable use of medical libraries, 
classrooms and conference rooms, as mutually agreed.
(c)  Jeff Johnston, MD or the succeeding Forensic Pathology fellowship program 
director serving as the Site Director for this rotation, shall be responsible for the instruction, 
supervision, and evaluation of the Residents assigned to the Clinical Facility, including all 
postmortem procedures, laboratory orders, report preparation, and toxicology and histology 
interpretation, performed in accordance with learning objectives.  The Mayo Clinic Program 
Director has ultimate responsibility to oversee Resident education.
(d)  Mayo Clinic agrees to designate for participation in the programs covered by 
this Agreement only Residents who have completed the necessary training and didactic work for 
such programs and are in good standing with their respective institutions.  Upon request, Mayo 
Clinic shall provide Clinical Facility with documentation of educational and legal authority for 
its Residents to participate in rotations at Clinical Facility, including proof of licensure or 
registration from all applicable state licensing boards.  
(e)  Mayo Clinic shall ensure that its faculty and Residents meet minimum health 
standards.  Upon request, Mayo Clinic and/or Resident shall provide Clinical Facility with a

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current health status report for each Resident prior to beginning the rotation through Clinical 
Facility.  The health status report may include, without limitation, (1) proof of immunity or 
immunization for measles, mumps and rubella, (2) proof of current diphtheria/tetanus 
immunization, (3) proof of immunity or immunization for varicella, (4) documentation of TB 
screen, (5) documentation of Hepatitis B antibody screen or signed declination, (6) proof of 
seasonal influenza and COVID-19 vaccinations or signed declinations, (7) medical clearance to 
wear a TB effective respirator, (8) training in Human Blood and Body Fluid Precautions, as set 
out by Occupational Safety and Health Administration (OSHA) regulations and (9) when 
appropriate for the specific rotation, documentation of completed background studies and drug 
screening. 
(f)  Where applicable, all parties certify that they are in good standing with their 
respective accrediting bodies, and upon request, will provide documentation of accreditation. 
(g)  Clinical Facility assumes full responsibility for the care of its patients.  
Residents do not have ultimate authority for decisions regarding the determination of decedent’s 
clinical diagnoses, procedures, and/or dispositions as this authority rests with OME Professional 
staff.  It is understood that Mayo Clinic does not derive direct revenue from patient care activity 
at Clinical Facility.
(h)   Clinical Facility will permit, on reasonable request, the inspection of its 
clinical and related facilities by Mayo Clinic and individuals or agencies charged with the 
responsibility for accreditation of Mayo Clinic’s graduate medical education training programs.
(i)  Clinical Facility will provide each Resident who has been approved for a 
rotation placement with all medical supplies including Professional Protection Equipment (PPE) 
and adequate TB effective respirator fit testing.  Residents will be responsible for complying 
with Clinical Facility practices regarding how and when to utilize the supplies including the 
frequency of changes of the PPE during a typical day shift.
2.
Health Insurance Portability and Accountability Act
(a)  Residents shall be instructed by Mayo Clinic prior to beginning the Program 
concerning the confidentiality of medical information of Clinical Facility’s patients and 
regarding standard precautions.  For purposes of compliance with the Health Insurance 
Portability and Accountability Act and associated privacy regulations (“HIPAA”), Residents 
shall be considered part of Clinical Facility’s workforce as that term is defined in HIPAA to 
include trainees and students.  Residents are not considered work force or employees of Clinical 
Facility for other purposes, including but not limited to tax or employment law. Clinical Facility 
shall provide the necessary training specific to HIPAA.  
(b)  Clinical Facility will permit the ACGME to access protected health 
information (as that term is defined under HIPAA) maintained by Clinical Facility to the extent 
required for the accreditation of Mayo Clinic’s graduate medical education training programs.  
The use and disclosure of such protected health information by the ACGME shall be governed 
by the Business Associate Agreement (“BAA”) that is maintained by Mayo Clinic with the 
ACGME or, to the extent applicable and in place, the BAA that is maintained directly by Clinical 
Facility with the ACGME.  Upon request, Mayo Clinic shall provide Clinical Facility with a 
copy of its BAA with the ACGME.  If Clinical Facility has entered into a BAA with the

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ACGME, Clinical Facility shall provide a copy of the BAA to Mayo Clinic upon Clinical 
Facility’s execution of this Agreement or promptly thereafter if the BAA is implemented after 
the effective date of this Agreement.       
3.
Policies and Procedures Governing Residents.  Residents shall be subject to 
and follow all Clinical Facility’s rules, regulations, policies and procedures, including standard 
precautions and confidentiality of investigations.  Residents enrolled in the program covered by 
this Agreement will also be governed in accordance with the policies and procedures established 
through Mayo Clinic’s programs.  
4.
Termination of Resident Experience.  Clinical Facility may terminate the 
participation of a Resident in a clinical experience if the Resident’s work, conduct or health may, 
in Clinical Facility’s judgment, have a detrimental effect on its patients, staff, or operations.  A 
Resident generally will not be removed from a clinical experience until Clinical Facility has 
discussed its concerns with a representative of the Mayo Clinic.  However, Clinical Facility 
reserves the right to take immediate action to suspend a Resident’s participation in response to 
concerns of patient care or the safety and respect of its staff.  Clinical Facility shall not be 
arbitrary or discriminatory in the exercise of this right.
5.
Resident Health Insurance and Emergency Medical Care.   Mayo Clinic shall 
ensure that each Resident has access to health insurance throughout the entire term of their 
training at Clinical Facility.  Resident shall be furnished emergency medical care and treatment, 
if needed, while on duty at Clinical Facility with the associated expense to be the responsibility 
of the Resident.
6.
Stipend and Additional Costs.
(a)  Mayo Clinic shall provide stipend and medical benefits to its Residents in 
accordance with its own policies and procedures.
(b)  Clinical Facility will not provide a stipend either in the form of pay or in kind 
to the Residents for services provided under this Agreement.
7.
Insurance.
(a)  If Clinical Facility is a Florida state owned and operated institution, the 
following language shall apply:  It is understood by the parties that Clinical Facility is an 
institution which is afforded sovereign immunity as described under Florida Statutes, Sections 
110.504 and 768.28.  Clinical Facility must notify Mayo Clinic if this law does not apply.
(b)  If (a) above does not apply, Mayo Clinic will provide and maintain insurance 
as described below:
 
(i) Professional liability insurance (or comparable coverage under a 
program of self-insurance) providing coverage on an “occurrence basis” 
for occurrences during the term of this Agreement with limits no less 
than $5 million per occurrence and $5 million aggregate.

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(ii) Comprehensive general liability insurance (or comparable coverage 
under a program of self-insurance) providing coverage on an  
“occurrence basis” for occurrences during the term of this Agreement 
with limits no less than $1 million per occurrence and $3 million annual 
aggregate.  
(c)  The insurance required in Section 7(b) above shall be in full force and effect 
prior to the arrival of Residents at Clinical Facility.  It shall not be modified or terminated except 
upon thirty (30) calendar days’ prior written notice to Clinical Facility.  In the event any “claims 
made” policy is procured to meet the insurance requirements hereunder, “tail” coverage shall 
also be procured for a period of four (4) years after termination of such policy. 
(d)  Upon request, Mayo Clinic shall provide Clinical Facility with a Certificate of 
Insurance evidencing the above-stated coverage.
(e)  Worker’s Compensation coverage for Residents participating in rotations at 
Clinical Facility shall be provided by Mayo Clinic.
8.
Liability.  Each party is solely responsible for any of its own claims, causes of 
action, liabilities, or the like that may arise out of this Agreement.  Furthermore, neither party 
shall compensate the other party for any of the foregoing.  The terms of this section shall survive 
expiration or termination of this Agreement.  
9.
Independent Contractors.  Each party is a separate and independent institution, 
and this Agreement shall not be deemed to create a relationship of agency, employment, or 
partnership between or among them.  Each party understands and agrees that this Agreement 
establishes a bona fide training relationship and that the agents or employees of each respective 
party are not employees or agents of the other party.  
10.
Term.   This Agreement shall be for a term of one (1) year, beginning on the last 
date signed below, and will be automatically renewed for subsequent one (1) year terms for a 
total of ten (10) years, unless earlier terminated as described in paragraph 11 below.  
11.
Termination.  
(a)  Either party may terminate this Agreement for any reason by giving at least 
ninety (90) days written notice to the other party.  The OME Chief Medical Examiner or their 
designee is authorized to provide notice of termination and to terminate this Agreement.
(b)  In the event that this Agreement is terminated pursuant to this paragraph, the 
parties hereby agree that no Residents participating in an ongoing experience will be denied the 
opportunity to complete the affiliation, even when the effective date of termination occurs prior 
to the completion date of the clinical experience.  In such event, all applicable provisions of this 
Agreement, including the right to terminate any Resident pursuant to Section 4, shall remain in 
force during the extension period from the effective date of termination, until the end of the 
academic term in which the Resident is enrolled.

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12. 
Amendments.  This Agreement may be amended from time to time by the written 
agreement of the parties.
13.
Notices.  Any notice under this Agreement shall be deemed sufficiently given if 
sent by facsimile, courier, electronic transmittal, or similar reliable means of delivery, with 
receipt confirmed. Such notice shall be directed as set forth below:
  
For Mayo Clinic:
Yasmeen M. Butt, MD
Program Director
Mayo Clinic Arizona
13400 East Shea Blvd 
Scottsdale, AZ 85259
Butt.Yasmeen@mayo.edu
With copy to:
Education Business Services
Siebens 5
Mayo Clinic
200 First Street SW
Rochester, MN 55905
EduAffiliations@mayo.edu
For Clinical Facility:
Administrative Director
Maricopa County
701 W Jefferson St
Phoenix, AZ 85007
amy.rex@maricopa.gov
14.
Use of Name. Except as specifically permitted in this Agreement, neither party 
will use the names or trademarks of the other party or any of the other party's affiliated entities in 
any news release, advertising, publicity, endorsement, promotion, or commercial communication 
without the prior written approval of the other party for the particular use contemplated. All 
requests for approval for the use of Mayo's name pursuant to this Section must be submitted to 
the Mayo Clinic Business Relations Group (BusinessRelations@mayo.edu) at least 7 business 
days prior to the date on which a response is needed. The existence and scope of the rotation 
available via this Agreement may be made known to Residents as a means of assistance in 
completing their training requirements. The terms of this Section survive the termination, 
expiration, non-renewal, or rescission of this Agreement.
15.
Assignment.  No party has the right or the power to assign this Agreement, in 
whole or in part, without the prior written consent of the other parties, and any purported 
assignment in contravention of this provision shall be null and void.  
16.
Governing Law.  This Agreement shall be construed in accordance with the law 
of the State of Arizona.
17.
Excluded Entity or Individual.  Each party shall immediately notify the other 
party in the event that it becomes excluded from any federal health care program.
18.
Enforceability and Waiver.  The invalidity or unenforceability of any term or 
provision of this Agreement shall in no way affect the validity or enforceability of any other term 
or provision.  The invalid or unenforceable provision shall be fully severable.  The waiver by a 
party of a breach of any provision of this Agreement shall not operate as or be construed as a 
waiver of any subsequent breach thereof.
19.
Non-exclusive Agreement.  Each party may enter into similar agreements with 
other training institutions, provided that such agreements do not materially interfere with the 
ability of each party to carry out its obligations hereunder.
             20.
Compliance with Laws.  Each party shall comply with all federal, state and local 
laws and regulations applicable to their respective operations, including, but not limited to, those

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dealing with employment opportunity, immigration and affirmative action such as 42 U.S.C. Sec. 
2000 (e) et seq., The Civil Rights Act of 1964, Sections 503 and 504 of the Rehabilitation Act of 
1973, Section 402 of the Vietnam Era Veterans' Readjustment Assistance Act of 1974, the 
Immigration Reform Act of 1986, the Americans with Disabilities Act of 1990 and any 
amendments and applicable regulations pertaining thereto.
21.
Entire Agreement.  This Agreement represents the entire agreement between the 
parties with respect to the subject matter hereof and supersedes all prior agreements and 
representations.
22.
Authority.  The persons signing this Agreement warrant that they have full 
authority to do so and that their signatures shall bind the parties for which they sign. Each party 
hereto consents to be bound by photocopy, scanned PDF, facsimile or electronic signatures of 
such party’s representative(s) hereto.

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IN WITNESS WHEREOF, the parties hereto have executed this Program Letter of Agreement as 
of the respective dates written below.
MAYO CLINIC SCHOOL OF GRADUATE 
MEDICAL EDUCATION
By:  _________________________________   
Name:  Yasmeen M. Butt, MD
Title:   Program Director
Date:  
By: _________________________________     
Name:  Nitin Mishra, MBBS, MPH
Title:  Senior Associate Dean; DIO Designee
Date:  
MAYO CLINIC ARIZONA
By: _________________________________     
Name:  David L. Dahlen
Title:    Administrator, Education
Date:  
MARICOPA COUNTY
By: _________________________________    
Name:  Jeff Johnston, MD
Title:    Site Director
Date:  
By:  _________________________________   
Name: 
Title:   Chairman, Board of Supervisors
Date:  
ATTEST:
_____________________________________
Clerk of the Board
Date: ________________________________
Approved as to form:
_____________________________________
Deputy County Attorney
Date: ________________________________
Mayo EBS
Reviewed by:
____________

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Attachment 1
GOALS AND OBJECTIVES
Maricopa County | Office of the Medical Examiner
Resident Rotation in Forensic Pathology
Rotation Goals:

By the end of the rotation, pathology residents will understand the role of medicolegal death 
investigations in other societal systems and gain experience through direct casework that 
enhances their medical skills and knowledge. 
Learning Objectives:
Organized below by core competencies and related ACGME milestones, by the end of the month-long 
forensic pathology rotation, pathology residents will be able to:
Patient Care and procedural skills

Autopsy
o
Review the investigative report and medical records and then formulate a list of 
questions the death investigation should attempt to answer and a case management 
plan.
o
Perform a standard forensic autopsy procedure in compliance with NAME forensic 
autopsy performance standards including documentation of external observations; 
evisceration of the torso, neck, and head; dissection of organs and tissues; 
documentation of internal observations; and specimen and evidence collection.

Interpretation and diagnosis
o
Distinguish between normal, artifactual, and abnormal gross and microscopic anatomy.
o
Select relevant ancillary testing.
o
Integrate histories, postmortem examination findings, and ancillary testing to develop 
and refine a differential diagnosis for cause of death and manner of death.  

Reporting 
o
Write a correctly formatted Medical Examiner Report that includes relevant death 
certificate information (cause of death, manner of death, and how injury occurred, if 
applicable); findings; a summary and opinion; postmortem examination observations; 
radiological observations; and microscopic examination observations.
o
Write cause of death statements that comply with best practices for death certification.
Medical Knowledge

Diagnostic knowledge
o
Demonstrate knowledge of anatomy, physiology, pathology, and toxicology relevant to 
medicolegal death investigations including being able to recognize patterns of trauma 
(blunt impact, sharp implement, and firearm-related), chemical intoxication, asphyxia, 
and sudden natural deaths.

Clinical reasoning
o
Determine information sources relevant to medicolegal death investigations.
o
Synthesize information into sound medical conclusions including diagnoses, findings, 
cause of death, and manner of death.

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Interpersonal and Communications Skills

Family and stakeholder-centered communications
o
Describe the role of a forensic pathologist in family and stakeholder communications.
o
Describe methods for communicating bad news to families effectively.
o
Describe the role of the family advocate and the benefits of such a position in 
medicolegal death investigation agencies. 
o
Describe the purpose of stakeholder communications and explain the process and risks 
of information sharing at different stages of a case.

Interprofessional and team communication
o
Demonstrate effective communications with team-members during active casework and 
leaning activities.
o
Describe the general styles/attitudes of communication including assertive, aggressive, 
passive, and passive-aggressive and the skills needed to utilize the assertive style. 
Professionalism

Professional behavior and ethical principles
o
Demonstrate professional behavior when working with other team-members, 
stakeholders, and decedent remains.
o
Describe ethical and unethical behaviors in medicolegal death investigations including 
treatment of decedent remains; information privacy and confidentiality; use of 
photographs and video; and media relations.  

Accountability and conscientiousness
o
Demonstrate accountability and conscientiousness by taking ownership of appropriate 
casework and completing tasks in a timely manner.

Self-awareness and help-seeking
o
Explain the terms vicarious trauma and compassion fatigue and methods for 
maintaining trauma resilience in medicolegal death investigation casework. 
o
Demonstrate awareness of personal and professional well-being by self-assessing and 
seeking assistance from appropriate faculty.   
Practice-based Learning and Improvement

Evidence-based practice and scholarship
o
Identify reliable reference sources for use in medicolegal death investigations.
o
Describe the general legal framework for research in forensic pathology including the 
boundaries around using casework in research.

Reflective practice and commitment to personal growth
o
Communicate their current learning goals for the rotation and develop a plan with 
faculty to work towards those goals. 
o
Explain the utility of seeking peer review in casework.
Systems-based Practice

Safety and quality improvement
o
Describe quality improvement methods in medicolegal death investigation work.
o
Describe safety practices in forensic pathology.

Systems navigation
o
List the positions that make up a medicolegal death investigation team and explain their 
roles and general areas of responsibility.
o
Describe the Medical Examiner’s role and interactions with Organ and Tissue 
Procurement Agencies.

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
Physician’s role in the system (forensic versus institutional death investigation)
o
Describe the different forms of death investigation, their roles in society, and legal 
requirements for each.
o
Describe the practice differences between forensic pathologists who operate as public 
officials and pathologists who operate in the private healthcare system.

Informatics
o
Describe how information systems are used in medicolegal death investigation systems 
including for casework, statistical analysis, and information sharing.

Accreditation, compliance, and quality
o
Describe the general legal framework medicolegal death investigation systems operate 
under.
o
Describe the general requirements for medicolegal death investigation agency 
accreditation and their benefits.
Duties and Responsibilities:

Perform at least five forensic autopsies under the direct supervision of a board-certified forensic 
pathologist and author the Medical Examiner Report.

Attend daily 7a.m. morning triage meetings on weekdays and present assigned cases.

Observe casework and read recommended references. 

Attend at least three incident scene evaluations.

Observe at least one pre-trial interview or in-court testimony, if possible.

Maintain a log of casework participation and observation.

Present to faculty on a forensic pathology or autopsy pathology topic of interest.
Evaluations:

Summative evaluations will be provided by faculty forensic pathologists who worked with the 
resident and the forensic pathology fellowship program director will provide a final 
performance evaluation.