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ATTACHMENT A

NORTON HEALTHCARE

STUDENT PRACTICE SITE ADDENDUM

THIS STUDENT PRACTICE SITE ADDENDUM(“Student Agreement”) is made and entered into as of 20____ (“Effective Date”), by ______(“Student”), who is a student at the University of Louisville School of Public Health and Information Sciences (“University”).

PURPOSE

University and Norton Healthcare (“Practice Site”) have entered into an affiliation agreement in which Practice Site is designated as and agrees to serve as a community-based public health practice site for one or more academic or professional programs of University (“Program”), and sets forth the responsibilities of the parties thereto and the terms and conditions of the affiliation established (“Affiliation Agreement”), which is incorporated herein by reference and has been provided to Student.

Student Agreement sets forth the terms and conditions under which Student is obligated during Student’s assignment to Practice Site as part of Program.

RESPONSIBILITIES OF STUDENT

  1. If required by University, Student will develop and execute, in conjunction with Practice Site and University, a Learning Contract that specifies the deliverables to Practice Site expected of Student as part of Student assignment at Practice Site. Such Learning Contract, however, shall not be construed as part of Student Agreement.
  1. Student acknowledges that costs for emergency medical care in the case of injury or illness during Student’s presence at Practice Site shall be borne by Student and Student’s health insurance, if any.
  1. Student acknowledges having received in-service training on HIPAA and human subjects’ protection provided by University. Student is subject to Practice Site’s policies and procedures governing the use and disclosure of protected health information.
  1. When deemed appropriate by either University or Practice Site, Student will, with assistance from University and Practice Site personnel, obtain either approval or exemption from an appropriate Institutional Review Board (“IRB”) prior to performing an activity at or for Practice Site that has been deemed to require IRB review.
  1. Student acknowledges that Practice Site owns Student’s work product done at or for Practice Site under Student Agreement and under a Learning Contract.
  1. Student acknowledges that in the event Practice Site owns Student’s work product, Practice Site will grant Student rights to use Student’s work product done under this Student Agreement and may require reasonable terms and conditions in the granting of such rights.
  1. Student acknowledges that Student’s work at or for Practice Site may be work done under the direction and supervision of Practice Site personnel.
  1. Student acknowledges that upon recommendation of Practice Site, University may withdraw Student from an assignment at Practice Site if Student does not abide by Practice Site’s rules and regulations or, for other reasons, is performing unsatisfactorily. Student further acknowledges that questions and disputes concerning Student’s removal from Practice Site assignment will be resolved by a joint conference between University and Practice Site personnel to which Student may or may not be invited at the sole and unreviewable discretion of University.
  1. Student acknowledges that all rules and regulations of Practice Site will apply to Student during Practice Site assignment, which may include requiring Student to sign a confidentiality or non-disclosure agreement with Practice Site.
  1. Student acknowledges that Student shall not receive compensation from Practice Site for any work done under the terms and conditions of Student Agreement.
  1. Student shall adhere to all applicable Norton policies, procedures, rules and regulations, including without limitation, to the policies relating to Infection Control Requirements for Health Care Affiliates and Educational Affiliations.
  1. Student grants permission to conduct at least annually, a search of the OIG-HHS Exclusion Database and the U.S. General Services Administration Exclusion Database and determine that no Student has been excluded from any Federal healthcare or procurement program. The student agrees to provide their social security number in order to have this search conducted.
  1. Prior to participation in the Program, Student shall participate in and complete all compliance training required by all new Norton employees, including but not limited to HIPAA compliance training, and in such additional components of Norton’s Compliance Program as determined to be appropriate.
  1. Student shall undergo annual compliance re-training as required for Norton employees.
  1. Student agrees to pay for a background investigation and submit the original to the Office of Student Services. The background check shall include a criminal background check that complies with law, regulation, and Norton policy to ensure these individuals are suitable for a patient care environment. Educational Institution shall provide written verification to Norton, upon request, that a background investigation was conducted in compliance with the foregoing requirements and that these individuals are suitable for work in a patient care environment.
  1. Student agrees to comply with Norton policies regarding drug testing. This includes paying for the drug testing and submitting the results to the UofL SPHIS Office of Student Services.
  1. When at the practice site the student shall wear a badge or other form of identification that includes, at a minimum, the individual’s first name, licensure credentials and position/title.
  1. Student agrees that any submission for publication of any material relating to the educational experience is strictly prohibited without the prior written approval from Norton. In such an event, Educational Institution and Norton shall execute a Data Use Agreement.

REQUIRED DOCUMENATION

The Student grants the University of Louisville (UofL) School of Public Health and Information Sciences (SPHIS) Office of Student Services permission to provide the following documentation to Norton Healthcare. Documentation received will be kept in accordance with University records retention requirements.

  • Background check
  • Drug test results
  • Immunization record
  • TB screen results

INTENDING TO BE LEGALLY BOUND, the parties cause Student Agreement to be executed by their duly authorized representatives, as of Effective Date.

For University:

______

Kathy Baumgartner, Ph.D., Associate Dean

School of Public Health and Information Sciences

University of Louisville

485 East Gray Street

Louisville, KY 40202

Recommended by:

______

Robert Jacobs, Ph.D.

MPH Program Director

School of Public Health and Information Sciences

University of Louisville

For Student:

______

Student named above

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