AFFILIATION AGREEMENT PACKET FOR DOCTOR OF NURSING PRACTICE PRACTICUM EXPERIENCE ADMINISTRATION AND ADVANCED PRACTICE NURSING STUDENTS.

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Administration, Advanced Practice, and Nurse Educator 1 3/13/2014

AFFILIATION AGREEMENT PACKET

FOR DOCTOR OF NURSING PRACTICE PRACTICUM EXPERIENCE ADMINISTRATION AND ADVANCED PRACTICE NURSING STUDENTS

And

MASTER OF SCIENCE IN NURSING- NURSE EDUCATOR STUDENTS

The Ida V. Moffett School of Nursing goal is to assist students in obtaining an excellent practicum experience. The School of Nursing has clinical affiliation agreements with numerous clinical

sites/organization. The affiliation agreement is a legal binding agreement between Samford University and the clinical site/organization. The purpose of the clinical affiliation agreement is to facilitate the working relationship between Samford University and the clinical site/organization in providing learning opportunities for students. The key to obtaining an affiliation agreement with a clinical site/organization is to work closely with your faculty and to start your planning EARLY.

An agreement MUST be in place before students can begin a practicum experience. Some clinical sites require additional documentation, in addition to obtaining an affiliation agreement that students must provide before beginning a practicum experience at the clinical site/organization. Please be sure to check with the clinical site to ensure that no additional documents are needed in addition to the affiliation agreement. In the event that additional documentation is needed, it is your responsibility to provide the clinical site with the additional documents.

The Practicum Experience Affiliation Agreement is a legal binding agreement between Samford

University and the clinical site/organization. An agreement MUST be in place between the University and the clinical site/organization before students can begin their clinical practicum. Before initiating an affiliation agreement, please check the Contract List for Administration, Advanced Practice, and

Nurse Educator Students to verify that a contract is not already in place with the clinical

site/organization with whom you wish to perform your practicum with. The contract list can be found at http://www.samford.edu/nursing. If the site is NOT on the list (meaning there is no active contract in place), you will need to complete a Contract Packet for Administration, Advanced Practice, and

Nurse Educator Students. The contract packet can be accessed through the Ida V. Moffett School of

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Administration, Advanced Practice, and Nurse Educator 2 3/13/2014 see the Contract Packet for Administration, Advanced Practice, Nurse Educator students. Print two (2) copies of the Contract Packet on CLEAN WHITE paper. Properly complete the affiliation agreement and deliver or mail both copies of the affiliation agreement to the clinical site/organization. Have the authorized legal representative for the clinical site/organization to sign both copies of the affiliation agreement and mail both copies to the address below. All inquiries regarding the affiliation agreement should be sent to [email protected].

Any questions concerning insurance may be referred to Ms. Glenn. If a certificate of insurance is required by the clinical site, please notify Ms. Glenn.

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AFFILIATION AGREEMENT

FOR DOCTOR OF NURSING PRACTICE PRACTICUM EXPERIENCE ADMINISTRATION AND ADVANCED PRACTICE NURSING STUDENTS

And

MASTER OF SCIENCE IN NURSING- NURSE EDUCATOR

This Agreement is made and entered into this ______ day of _______________, 20___ by and between Samford University, hereinafter referred to as “University”, and _________________________ hereinafter referred to as the “Facility.”

RECITALS:

A. The Facility provides experiences that are suitable for instruction of graduate nursing students. B. The University operates a graduate program of study in nursing through its Ida V. Moffett School

of Nursing, hereinafter referred to as the “School of Nursing.” This program is in compliance with accepted standards for national accreditation by the Commission on Collegiate Nursing Education.

C. The University desires to provide its graduate nursing students with learning experiences, hereinafter referred to as the “Program,” and the Facility desires to provide its facilities to facilitate this program.

In consideration of the mutual covenants and agreements herein set forth, the University and Facility agree as follows:

I. The UNIVERSITY AND THE SCHOOL OF NURSING RESPONSIBILITIES:

The University and the School of Nursing will:

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Administration, Advanced Practice, and Nurse Educator 4 3/13/2014 b. require that each student participating in the Nursing Program has health insurance, a

current physical examination, and the following vaccinations: Rubella, Varicella, Hepatitis B, and a Tuberculin Skin Test. The School of Nursing will agree to require its students participating in the Program to furnish the Facility any documentation required by the Facility showing that the student has had the required vaccinations and/or physical examination.

c. be responsible for the instruction and summative evaluation of each graduate nursing student enrolled in the graduate program.

d. designate a member of the School of Nursing Faculty to serve as the Student’s Faculty Advisor in coordinating activities and other aspects of this Agreement with the Preceptor, subject to Facility’s approval which shall not be unreasonable withheld. e. designate a Faculty Advisor to be responsible for assisting the graduate nursing student

in developing the educational objectives of the Program and consulting with the Preceptor in advance regarding the nature of Student’s Program activities.

f. designate a Faculty Advisor that will provide orientation sessions for the Preceptor which will include (1) the overall philosophy and goals of the program; (2) expectations of Preceptors including feedback about the students; (3) how the Preceptor can reach the Faculty; (4) what to expect from graduate nursing students at various levels of the Program in terms of knowledge and skill; (5) objectives for learning experiences; (6) what the Preceptor can expect of School of Nursing faculty; (7) an overview of teaching strategies with an emphasis on principles of adult learning; and (8) an introduction to evaluation of students; including the format used by the Program.

g. THE OFFICE OF INSPECTOR GENERAL’S (“OIG”) LIST OF EXCLUDED

INDIVIDUALS/ENTITIES. The School of Nursing will screen students against the Office of

the Inspector General List of Excluded Individuals/Entities (“OIG) and the General Services Administration’s Excluded Parties List (“GSA”) to verify as of the Effective Date of the contract, that students have not been convicted of a criminal offense, assessed civil money penalties pursuant to the Civil Monetary Penalties Law, or excluded from the Medicare program or any state health care program.

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Administration, Advanced Practice, and Nurse Educator 5 3/13/2014 terminated, or otherwise modified, such students shall not be assigned to the hospital or clinical facility.

i. BACKGROUND CHECK. The School of Nursing will (i) perform a criminal and county background check, (ii) check the sex offender registry, (iii) perform a social security trace; (iv) obtain a 10 panel drug screen on each student enrolled in the Program. j. DRESS CODE. The School of Nursing will require the students to dress in accordance

with the dress and personal appearance standards approved by the faculty. Such standards shall be in accordance with the Facility’s standards regarding the same.

II. FACILITY’S RESPONSIBILITIES: The Facility will:

a. make clinical facilities, supplies, equipment and preceptorships available to the faculty and students in the graduate program.

b. meet and maintain accepted standards of the appropriate accrediting/nursing agencies. c. provide an orientation for graduate nursing students of the School of Nursing which will

familiarize such students with Facility policies and facilities.

d. provide Facility administrative personnel to assist the School of Nursing faculty with the selection of experiences and activities in the graduate program.

e. acknowledge and agree that the Preceptor shall be responsible for supervising the education and experience of the graduate nursing student and shall act as the clinical liaison to School of Nursing in implementing the terms of this Agreement. Preceptor shall be responsible for cooperating with the Faculty Advisor designated by School of Nursing to assure mutual participation and supervision of the Program.

f. maintain full responsibility for the care of patients in the clinical areas in which the clinical program is conducted when appropriate.

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Administration, Advanced Practice, and Nurse Educator 6 3/13/2014 h. agree that graduate nursing students enrolled in the graduate program shall be and

remain students of the University and shall in no sense be considered employees of the Facility.

i. provide emergency treatment for injuries received by students and faculty members while in the Facility and engaged in their work and study therein and that the cost of such treatment shall be responsibility of the injured individual.

j. provide adequate meeting and conference space and access to library facilities, if applicable, when arranged in advance by School of Nursing.

k. allow students and faculty members at their own expense to use the Facility’s cafeteria, if applicable.

l. allow vehicular parking at the Facility for students and faculty members. To the extent there is a charge for parking, such charge will be paid by students and faculty; and m. reserve the right to approve in advance (1) the number of graduate nursing students to

be assigned to the Facility and (2) the dates and times of the clinical experiences. n. Neither party shall be responsible for costs or expenditures incurred by the other in the

conduct of the educational program.

III. PRECEPTOR’S RESPONSIBILITIES: The Preceptor will:

a. obtain informed consent from patients attended by Preceptor when instructing,

supervising or evaluating the graduate nursing student in the provision of direct patient care as necessary.

b. include the graduate nursing student in appropriate educational seminars or observations.

c. periodically evaluate the graduate nursing student’s progress and performance. d. inform faculty of unacceptable graduate nursing student performance.

e. notify the University of any incidences involving a student which may give rise to claims against professional liability coverage of any student and to cooperate with the

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Administration, Advanced Practice, and Nurse Educator 7 3/13/2014 f. notify facility of the graduate student’s practicum and the student of any facility

requirements, prior to initiation of experience.

g. sign a separate preceptorship planning form for each graduate nursing student.

IV. THE GRADUATE NURSING STUDENT RESPONSIBILITIES: The Graduate Student will:

a. present evidence of an unencumbered license as a R.N. in the state of practice. b. present evidence of CPR certification.

c. abide by all lawful policies and procedures of the Facility/Preceptor.

d. maintain the confidentiality of all patient medical information obtained in the performance of Program responsibilities.

e. obtain prior written approval from Preceptor and School of Nursing before publishing any materials relating to the Program.

f. fulfill responsibilities as outlined in this agreement.

g. participate in orientation procedures as required by facility.

h. conform with all Facility policies and procedures. Graduate nursing students who fail to so conform are subject to removal from the graduate program upon mutual agreement by both parties.

V. OBSERVATION- ONLY STUDENTS

a. Samford University and Affiliate agree that certain Students shall be assigned to the Clinical Agency for Educational Experiences which will be limited solely to observation and will involve no direct, hands-on patient care (“Observational Students”).

b. Samford University and Affiliate agree that, except as set forth in this Subsection V, all other terms and conditions of this Agreement shall apply to Observational Students.

VI. TERM AND TERMINATION:

a. This Agreement may be modified only by written amendments signed and acknowledged by both parties.

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Administration, Advanced Practice, and Nurse Educator 8 3/13/2014 c. This Agreement may be immediately terminated by either party at any time by the

failure of the other party to adhere to any material term hereof.

VII. INSURANCE:

a. The University hereby assures the Facility that the University and the student have Professional Liability Insurance with limits not less than $3,000,000 aggregate and the Facility is not obligated to furnish such coverage. An original certificate of insurance will be provided to the Facility upon request.

b. The Facility will obtain and maintain throughout the term of this Agreement or any renewal thereof, professional liability insurance coverage insuring its personnel for claims and/or damages resulting from the rendering or failure to render services by Hospital, its employees or agents with limits of liability coverage of not less than $1,000,000 per claim; $3,000,000 in the aggregate; subject to the University’s approval for adequacy of coverage. An original certificate of insurance will be provided to the University upon request.

VIII. INDEMNIFICATION AND NOTIFICATION OF CLAIMS:

a. The University will indemnify the Facility from any and all liability, loss or damage the Facility may suffer as a results of claims, demands, costs or judgments against it arising out of the University’s performance of this Agreement.

b. The Facility will indemnify the University from any and all liability, loss or damage the University may suffer as a result of claims, demands, costs or judgments against it arising out of the Facility’s performance of this Agreement.

c. The University will not make any claim against the Facility for any injury to a graduate nursing student or faculty member of the School of Nursing arising out of the

performance of this Agreement. The Facility will not make any claim against the University for any injury to Facility personnel arising out of the performance of this Agreement.

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Administration, Advanced Practice, and Nurse Educator 9 3/13/2014 e. Notwithstanding any provision to the contrary contained in this Agreement, the Facility,

under no circumstances, shall be liable for the negligence or misconduct of the

University, its agents, servants, employees, successors or assigns, or persons under the supervision of the University.

f. Each party agrees to give the other notice in writing, within 30 days, of any claim made against it that is covered by this section.

IX. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT:

University agrees to abide by the regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as it exists from time to time, as applicable. To the extent required by the provisions of HIPAA and the regulations promulgated there under and as such regulations exist at any time during the term of this Agreement, the University will protect Protected Health Information (as defined by HIPAA) that it obtains as a result of providing services under this Agreement.

Except as otherwise noted in this Memorandum of Agreement, the Ida V. Moffett School of Nursing may use Protected Health Information in the following manner:

(a) for the proper management and administration of Samford, provided that any disclosures are required by law, or Samford obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and the person notifies Samford of any instances of which it is aware in which the

confidentiality of the information has been breached;

(b) to provide Data Aggregation services to Samford as permitted by 45 CFR '164.504 (e)(2)(i)(B), and

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X. NOTICE

Any notices to be given hereunder by either party to the other shall be effected in writing either by personal delivery or delivery by mail, registered or certified, postage prepaid with return receipt requested. Mailed notices shall be addressed to the parties at the addresses appearing in this section, until and unless such party changes the specified address by written notice to the other.

If to University: Tinisha Glenn

Contracts Coordinator, Graduate Program Ida V. Moffett School of Nursing

Samford University 800 Lakeshore Drive Birmingham, Alabama 35229 If to Facility: ______________________________________ ______________________________________ ______________________________________ X. GENERAL PROVISIONS

a. Independent Contractor Status. Each party hereto shall be considered an independent

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b. Severability. If any part of this Agreement should be held to be void or unenforceable, such

part shall be treated as severable, leaving valid the remainder of this Agreement notwithstanding the part or parts found void or unenforceable.

c. Written Amendments. This Agreement cannot be amended, modified, supplemented or

rescinded except in writing signed by both parties hereto. No waiver of any provision of this Agreement shall be valid unless such waiver is in writing signed by both parties.

d. Entire Agreement. This Agreement constitutes the entire agreement between the parties

hereto with respect to the subject matter herein and supersedes any other agreements, restrictions, representations, or warranties, if any, between the parties hereto with regard to the subject matter herein.

e. Heading: Number And Gender. The headings of this Agreement are inserted for convenience

only and are not to be considered in the interpretation of this Agreement. They shall not in any way limit the scope of modify the substance or context of this Agreement. They shall not in any way limit the scope or modify the substance or context of any Sections of this Agreement. When required by the context, each number, singular and plural, shall include all numbers and each gender shall include the feminine, masculine and neuter.

f. No waiver. If in one or more instances a party fails to insist that the other party perform any

of the terms of this Agreement, such failure shall not be construed as a waiver by such party of any past, present or future right granted under this Agreement; the obligations of both parties under this

Agreement shall continue in full force and effect.

g. Assignment. This Agreement is not assignable, but is binding on the corporate successor of

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h. Third-parties. This Agreement is not a third party beneficiary contract, and confers no rights

upon any students or employees of the parties.

i. Non-Discrimination. Samford University is an Equal Opportunity Institution that complies

with applicable law prohibiting discrimination in its educational and employment policies and does not unlawfully discriminate on the basis of race, color, sex, age, disability, veteran status, genetic

information, or national or ethnic origin.

THE PARTIES HERETO, through their duly authorized representatives, have executed this Agreement as of the day and year first above written.

Samford University Facility

By: _____________________________ By: ___________________________ Title: ___________________________ Title: __________________________ Date: __________________________ Date: __________________________

FACILITY ADDRESS and PHONE NUMBER: