AFFILIATION AGREEMENT
BETWEEN
SOUTHEASTERN LOUISIANA UNIVERSITY
AND
AGENCY NAME
AGREEMENT made this DATE, between, Southeastern Louisiana University College of Nursing and Health Sciences, (hereinafter referred to as “University”) and, AGENCY NAME (hereinafter referred to as “Affiliate”).
WITNESSETH:
WHEREAS, Southeastern Louisiana University is an educational institution organized and operated under the authority of the University of Louisiana Systems which provides among its courses the training of students for careers in health care fields (nursing, kinesiology and health studies and Health and Human Sciences – communication sciences and disorders, family and consumer sciences and social work) at the University and
WHEREAS, the purpose of this Agreement is to provide high quality clinical education experiences for certain students enrolled health care fields in the College; and
WHEREAS, in the training of students for a career in health care, clinical education is desired, and Affiliate has facilities for such clinical education and Affiliate desires to associate with Southeastern Louisiana University in providing such facilities to Southeastern Louisiana University and its students in an environment that is conducive to the educational process.
NOW, THEREFORE, the parties hereto, intending to be legally bound hereby, agree as follows:
I. THE UNIVERSITY SHALL:
A. Administer the health care field programs and correlate the clinical experience assignments with the curriculum, didactic instruction, and academic level of the students.
B. Be responsible for the entire educational experience of the individual student enrolled in the different health care field programs. Southeastern Louisiana University may provide Affiliate with specified clinical objectives for student clinical practice experience and may work with Affiliate’s designated staff to implement the objectives. Southeastern Louisiana University retains responsibility for supervision, instruction, evaluation, as well as the determination of all grades to be awarded to the student.
C. Provide the number of students (agreeable by both parties) to be assigned for each rotation at the Affiliate by the beginning of each semester.
D. Maintain professional and general liability coverage with limits of $5,000,000 per occurrence covering the University, its faculty, and each student enrolled in health care field program. Southeastern Louisiana University agrees to provide certificate of insurance evidencing the above coverage. In the event that the policy is in claims made form, Southeastern Louisiana University agrees to purchase appropriate tail coverage. In the event of insufficient coverage, Affiliate reserves the right to terminate this Agreement.
E. Assure that enrolled student(s) meet health requirements of facility.
F. Have on record a complete physical examination of each student showing:
a. History of immunization against:
(1) Measles- initial immunization and if born before 1957, a booster.
(2) Mumps- initial immunization.
(3) Rubella- initial immunization
b. No active Tuberculosis
c. Any history of Hepatitis A, B, or C and existence of a carrier state. If present, this information must be communicated to the Affiliate. Also, Southeastern Louisiana University record should show that Heptavax B vaccine has been given or a Declination form has been signed.
d. History of Chicken Pox.
G. Represents that it will timely conduct a background check on each and every student for affiliates requiring background checks on employees unless the Affiliate waives this requirement. Said background check shall include, at a minimum, the following:
a. Social Security Number Verification
b. Criminal Search (7 years or up to 5 criminal searches);
c. Employment Verification to include reason for separation and eligibility for re-employment for each employer for 7 years (not required for students younger than 21 years of age);
d. Violent Sexual Offender and Predator Registry Search;
e. HHS/OIG List of Excluded Individuals/Entities,
f. GSA List of Parties Excluded from federal Programs;
g. Education Verification (Highest Degree Received);
h. U.S. Treasury, Office of Foreign Assets Control (OFAC), List of Specially Designated Nationals (SDN);
i. Applicable State Exclusions List, if one.
H. Represents that it will timely conduct (or will have timely conducted) a drug and alcohol test on each and every student for affiliates requiring background checks on employees unless the Affiliate waives this requirement. Said background check shall include, at a minimum, the following:
a. To ensure the accuracy and fairness of the testing program, all collection and testing will be conducted pursuant to guidelines established by the Medical Review Officers of the testing facility and, if applicable, in accordance with Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines; a confirmatory test; the opportunity for a split sample; review by an MRO, including the opportunity for employees or students who test positive to provide a legitimate medical explanation, such as a physician’s prescription, for the positive results; and a documented chain of custody.
b. Substances tested prior to placement at Affiliate must at a minimum include amphetamines, barbiturates, benzodiazepines, opiates, marijuana, codeine and cocaine. Reasonable suspicion and reportable accident testing should include amphetamines, barbiturates, benzodiazepines, carisoprodol, opiates, fentanyl analogues, methadone, meperidine, marijuana and cocaine.
I. Provide the Affiliate with evidence that the student is certified in Basic Cardiac Life Support.
J. Assume any and all obligations imposed by Workmen’s compensation Law of Louisiana insofar as a member of its faculty may sustain injury or disability arising out of, or in the course of, instruction by a member of its faculty.
K. Notify Affiliate, in writing, of any changes in policy of Southeastern Louisiana University which might affect the Affiliate status or responsibility.
II. THE AFFILIATE SHALL:
A. Indicate the staff members (mutually agreeable to Affiliate and the University) who will assume responsibility for assisting in the Program. Such staff members will assume this responsibility as part of their staff duties, compensation for which is the sole responsibility of the Affiliate.
B. Provide, planned, varied, constantly supervised clinical learning experiences as outlined in the curriculum and assure an environment that shall be conducive to the educational process.
C. Assure that students are not exploited in terms of duties normally expected of other Affiliate staff members.
D. Provide conference room, classroom, library facilities, dining facilities, and dressing and locker space for the students as feasible.
E. In consultation with the University, designate those patients to whom students may be exposed for their clinical education experience hereunder. Affiliate retains ultimate responsibility of patient care.
F. Affiliate shall maintain professional and general liability insurance on behalf of itself, its agents and employees in the amount of $5,000,000 for each occurrence.
G. Determine priorities for the use of facilities and available space between competing affiliations, in the event more than one such agreement exists.
H. Notify the University, in writing, of any Affiliate policy changes which might be in conflict with proper student education, or which might affect the University'’ responsibilities.
III. FEES:
The financial support of the program shall be provided through tuition paid to the University.
IV. STUDENT PARTICIPATION:
Affiliate will provide orientation and instruction for University faculty regarding administrative policies and procedures of Affiliate. Students and University faculty will be subject to all Affiliate policies and procedures and are fully expected to adhere to and comply with all applicable rules, regulations and laws of the State of Louisiana and the Federal Government.
Students and faculty members will respect the confidential nature of all information, which may be obtained during the course of their placement at Affiliate.
If a student assigned to Affiliate does not perform in accordance with minimum standards (as agreed upon by Affiliate and Southeastern Louisiana University), fails to conduct himself or herself in accordance with Affiliate’s rules and regulations or to appear at Affiliate as scheduled, Affiliate may terminate its relationship with the student following notice to student, consultation with Southeastern Louisiana University and an opportunity for the student to cure any such deficiencies.
Affiliate shall have the right at any time to take whatever action it deems necessary, including the barring of a student or faculty member from its premises in order to ensure the safety and welfare of its patients and to maintain the operation of its facilities free from disruption.
V. REMUNERATION:
Affiliate shall not pay students any remuneration for time spent at Affiliate’s facilities by students. During the Program, students will in no event become or be construed to be employees or agents of the Affiliate.
Affiliate will not assume any responsibility for any compensation, medical, professional, meal, travel, or other incidental expenses incurred by the students or University faculty in connection with the Program.
VI. TERM AND TERMINATION:
This Agreement is effective as of the date of signature , and will continue in full force until terminated in writing by either party with six months’ notice.
VII. HOLD HARMLESS:
A. Southeastern Louisiana University, shall indemnify, defend and hold harmless AGENCY NAME from any or all claims, demands, and expenses of any kind, including attorney’s fees, which result from or arise out of any act or omission of its students or faculty members relating to the terms and conditions of this Agreement.
B. AGENCY NAME shall indemnify, defend and hold harmless Southeastern Louisiana University from any or all claims, demands and expenses of any kind, including attorney’s fees, which result from or arise out of any act or omission of its agents and employees relating to the terms and conditions of this Agreement.
VIII. MISCELLANEOUS PROVISION:
A. Entire Agreement. This Agreement represents the entire understanding of the parties relative to the subject matter hereof. It may be changed only by an instrument in writing signed by the parties.
B. Notices. All notices, requests, demands and other communications hereunder shall be in writing and shall be deemed to have been duly given if personally delivered or, if mailed, when mailed by United States first class, certifies or registered mail, postage prepaid, to the other party at the following addresses (or at such other address as shall be given, in writing by any party to the other):
University: Southeastern Louisiana University
College of Nursing and Health Sciences
SLU 10781
Hammond, LA 70402
Attention: Ann K. Carruth, DNS, R.N.
Dean, College of Nursing and
Health Sciences
Affiliate: AGENCY NAME
ADDRESS
Attention: AGENCY REPRESENTATIVE
TITLE
C. Assignment. This Agreement may not be assigned in whole or in part by either party.
D. Governing Law. This Agreement has been made, executed and delivered in, and is to be governed and construed in accordance with the laws of the State of Louisiana.
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed the day and year first above written.
FACILITY OFFICIAL NAME SOUTHEASTERN LOUISIANA UNIVERSITY
BY: BY:
Authorized Signature Date John L. Crain Date
Title President
BY:
Tammy Bourg Date
Provost and Vice President for Academic Affairs
BY:
Ann K. Carruth, DNS, R.N. Date
Dean, College of Nursing & Health Sciences
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