OPERATING AGREEMENT FOR SCHOOL-BASED HEALTH CLINIC
EXHIBIT A-1
PLEASE COMPLETE ONE INFORMATION FORM FOR EACH SCHOOL SITE WHERE SERVICES WILL BE DELIVERED.
Clinic Site:
Name of Provider:Executive Director: / Title:
Business Address:
/ Telephone:City, Zip code:
/ Fax: ______Provider Contact:
School ______District______SPA ______
School Contact ______Title ______Telephone______
Feeder school(s) served by this site______
Describe the location(s) on the school site where services will occur:
______
Identify the District’s on-site staff member(s) that will liaison with Provider’spersonnel(Mental Health Services must also establish a liaison with a Student Personnel Service Credential holder):
Name:______Title:______Credential: ______
Name:______Title:______PPS Credential: ______
Supervision of Provider Interns, Residents, and Staff:The supervision of staff of a Provider is the responsibility of the Provider. A plan for staff supervision should be provided detailing the frequency and location of supervision and the certification or licensure of the supervisor (Attachment A-4). The malpractice and general liability insurance of the Provider is expected to cover the interns brought to the school by the Provider.
Describe the SUPERVISION PLAN for interns, residents, or other staff in training:
______
______
______
______
______
______
25
EXHIBIT A-2
HOURS OF OPERATION
PLEASE COMPLETE ONE INFORMATION FORM FOR EACH SCHOOL SITE WHERE SERVICES WILL BE DELIVERED.
Clinic Site:______
Days in Operation / Regular Hours / SchoolPopulations /
Population(s)
Served*Mental Health:
On-Site Pharmacy:On-Site Laboratory:
On-Site Radiology:
Evening Hours:
Weekend Hours:
Other:
*e.g. adolescents, parenting teens, preschool, parents,community
26
EXHIBIT A-3
Additional Services to be Provided
PLEASE COMPLETE ONE INFORMATION FORM FOR EACH SCHOOL SITE WHERE SERVICES WILL BE DELIVERED.
Clinic Site:
MENTAL HEALTH (check all that apply) Individual Child Therapy / Case Management / Clerical & Translation
Family Therapy / Training / Education Classes
Group Therapy / Pre-Service Interns / Parenting Classes
Faculty Consultation / Health Insurance Enrollment / Mental HealthSensitive Services
Information & Referrals / Substance Abuse Prevention / D.M.H. #:
DMH Sector Chief (if applicable):
HEALTH SERVICES (check all that apply)
Immunizations / Reproductive Health Services
Physical Exams / Mantoux Testing
Testing
Dental Screening Dental Sealant / Substance Abuse
Fluoride Treatment Dental Treatment / Clerical & Translation
Vision Screening Refraction / Pharmacy
Dispensing of Glasses / Pregnancy and Contraceptive Services
Medical Diagnosis & Treatment Services / Other ______
Please describe referral plans to link students to higher level of care and describe after-hours care:
______
______
______
______
______
27
19-Jun-00
OPERATING AGREEMENT FOR SCHOOL-BASED HEALTH CLINIC
EXHIBIT A-4
PLEASE COMPLETE ONE INFORMATION FORM FOR EACH SCHOOL SITE WHERE SERVICESWILL BE DELIVERED.
SITE NAME / LIC. TYPE / LIC. NO. / EXP.
DATE / TB
DATE / INTERN / CLERICAL / SUPERVISOR / OTHER
28
19-Jun-00
OPERATING AGREEMENT FOR SCHOOL-BASED HEALTH CLINIC
EXHIBIT A-5
DEFINITIONS
1. Primary Care Services: Coordinated and comprehensive health care, available both on a first contact and continuous basis in an outpatient setting. Primary care providers may include physicians, mid-level practitioners such as physician assistants, nurse practitioners, and licensed vocational nurses. Primary care emphasizes the student’s general health needs as opposed to a more specialized or fragmented approach to medical care.
- Medical diagnosis and treatment;
- Mental health diagnosis and treatment;
- Age appropriate immunizations and examinations;
- Prevention of disability and disease detection, education, persuasion, treatment;
- Maintenance of students with chronic illness;
f.Communication of information about diagnosis treatment, prevention, and prognosis; and,
g.Case management.
The primary care provider shall initiate referrals for follow-up care or diagnosis to specialists, as appropriate, and maintain continuity of student care.
For categorization purposes only, primary care may include services such as family planning, prenatal, pediatric, and ambulatory care services.
- Encounter:A face-to-face visit between a student/patient and a licensed, registered, or certified health care provider who exercises independent judgment in the provision of preventive, diagnostic, or treatment services.
29
An Encounter shall include diagnosis and medical treatment services, including any ancillary services that are
needed as a result of the Encounter. For a health service to be defined as an Encounter, the contact and provision of the health service must be recorded in the student’s record.
Telephone communications/consultations shall not be considered a face-to-face Encounter. To meet the Encounter criteria for independent judgment, a clinic provider must be acting independently and not assisting another provider.
3. Case Management:The coordination of all services. Case management
includes the use of appropriate approaches in service delivery (including, but not limited to, telephone access to after-hours nurse, as applicable, for clinical consultation and direction, health education classes on diabetes, asthma, or hypertension management as well as symptom management, social services, and referrals for benefits counseling) that are outcome-oriented and stress the maintenance of the students’condition. For a case management episode to be defined as a valid encounter, the contact and provision of the health service must be recorded in the student's record.
- Public Health Services: Provider shall cooperate with Director during communicable disease out-breaks, back-to-school immunization drives, traveling STD efforts, or other public health emergencies.
5. Screening and Informing and linkage to enrollment in Health Access and insurance programs available to children.
30
Exhibit C
Los Angeles Unified School District
ETHICS POLICY STATEMENT
For purposes of this policy statement, the term employees is intended to include: officers, commissioners, appointed committee members, independent contractors and consultants, volunteers and other representatives of the District in addition to all paid employees.
At the Los Angeles Unified School District, it is critical that all employees strive for excellence in the public service that they provide. As an employee of the District, you are expected to conduct yourself fairly, honestly and with the highest integrity. This means treating co-workers, students, parents, and other customers with respect, and in a manner that is exactly the way you would want to be treated. This also means being respectful of the District's resources and property. Recognizing that each of us plays a critical role in student success, striving for excellence is not only a personal commitment, but a personal responsibility that all District employees share.
This code of ethics provides general guidelines for employees to follow in carrying out their critical roles as District employees. Not all ethical issues that employees face on the job are covered in this code. However, the code does capture some of the critical areas that help define ethical and professional conduct for District employees. The provisions of this code were developed from existing laws, rules, policies and procedures as well as from concepts that define generally accepted good business practices. Employees are expected to strictly adhere to the provisions of this code of ethics.
This code of ethics is consistent with statutes addressing conflict of interest and supplements those provisions of law.
EMPLOYEE AND STUDENT RELATIONS. District employees are entrusted with the physical and mental well-being of every student. Therefore, employees shall treat students with respect and care and be aware of their proper roles as public servants, role models and contributors to student development. Employees shall not exploit, harass, or discriminate against any student or require students to perform work or service that could be detrimental to their health.
ACTIONS AND CONDUCT OF DISTRICT EMPLOYEES. District employees shall not only be aware that public service is a public trust, but also conduct themselves, both inside and outside the school district's services, in a manner that deserves the respect of the students, parents and the communities the District serves.
33
CONFLICT OF INTEREST. Employees shall not make or influence a District decision which will benefit the employees outside employment, business, or personal finances or benefit a family member or personal friend. (For provisions relating to private instruction, see Board Rule 1272.)
ACCEPTANCE AND OFFERING OF GIFTS, FAVORS AND GRATUITIES.Employees of the District shall not accept any gifts, money, or favors which might reasonably be interpreted as an attempt to influence their actions with respect to District business. It will be presumed that gift(s) valued in excess of $100 during a calendar year from any single person or organization (exclusive of gift exchanges based on personal relationships outside of the District) constitute an attempt to influence official District business. Employees shall not offer gifts, money, or favors which might
be interpreted as an attempt to influence the official actions of another employee or service provider with respect to District business.
DISTRICT RECORDS. District employees shall not create, in any manner, false, misleading, or artificial documents or entries in District accounts, time reporting records or other manual or electronic records. Records and related documents must be maintained in accordance with relevant laws and regulations.
USE OF CONFIDENTIAL INFORMATION. Employees of the District shall not disclose confidential information acquired by them in the course of their employment with the school district, or use such information for speculation or personal gain.
USE OF DISTRICT FACILITIES, EQUIPMENT AND EMPLOYMENT STATUS. Employees shall not use the District's facilities, equipment, or supplies for other than District authorized purposes. Employees shall not use or attempt to use their position to secure unwarranted privileges for themselves or others. (For provisions relating to prohibited and approved activities on school premises, see Board Rule 1251.)
OUTSIDE EMPLOYMENT. District employees shall not use their authority over a particular matter to negotiate future employment with any person or organization. Employees shall not make or influence a District decision involving the interests of a person with whom they have an agreement concerning current or future employment, or remuneration of any kind. For one year after leaving District service, former District employees may not represent any person or organization for compensation other than the District in connection with any matter pending before the District that, as District employees, they participated in personally and substantially. Nothing in this paragraph shall be taken to limit in any manner the outside employment of employees where the interests of the District are protected.
34
CONDUCT WITH RESPECT TO PERFORMANCE ON THE JOB. Employees of the District are responsible for, and accountable for, the performance of the specific assignments they are employed to perform. Employees shall not conduct personal business or outside employment activities during their assigned District work hours.
COMMITMENT. District employees are expected to uphold the federal and California Constitutions, the laws and regulations of the United States and the State of California (particularly the Education Code) and all other applicable government entities, and the policies, procedures, rules and regulations of the Los Angeles Unified School District Board of Education.
FAIRNESS. District employees are expected to conduct themselves in the course of their employment by word, gesture, act, and demeanor to ensure that all others are given fair and just consideration, regard and treatment. Understanding that, employees are encouraged to, and should, report unethical or fraudulent practices. Employees shall not be subject to retaliation for so doing.
35
19-Jun-00