WASHINGTONSTATEUNIVERSITY

StudentAffiliationAgreement

ContractNo. ______

THISAGREEMENTismadeandenteredintobetweenWashingtonStateUniversity, by and through its Speech and Hearing Sciences Department within the College of Medical Sciences (“WSU”),locatedatSpokane,Washington,and(“TrainingSite”),locatedat, (hereinafterreferredtosometimesas“Party”or“Parties”).

RECITALS:

WSU’scurriculumforeducatingmedicalcareprofessionalsincludesaclinicallearningexperienceforthestudentsenrolledinthedegreeprogramforthatprofession;and

TrainingSitehassuitableclinicalexperiencesandfacilitiesavailablefortheclinicallearningexperienceofsuchstudents;and

ItismutuallybeneficialtoWSUandTrainingSitetohaveWSUstudentsparticipateintheirclinicallearningexperienceatTrainingSite.

THEPURPOSEOFTHISAGREEMENTistosetforththedutiesand responsibilities of theTrainingSiteandWSUwithrespecttotheclinicallearningexperiencesprovidedattheTrainingSiteforstudentswhoareenrolledinWSU’scourseofstudy(the“educationprogram”).Asconsiderationforthemutualcovenantsandagreementscontainedinthisdocument,WSUandTrainingSiteagreeasfollows:

1.GENERALPROVISIONS

a.WSUandTrainingSiteagreethatcontemporaneouswithorfollowingexecutionofthisAgreement,andwithinthescopeofitsprovisions,WSUandTrainingSitemaydevelopletteragreementstoformalizeoperationaldetailsoftheclinicaleducationprogram. Thesedetailsinclude,butarenotlimitedto,thefollowing:

  • Beginningdatesandlengthofexperience(tobemutuallyagreeduponatleastonemonthbeforethebeginningoftheclinicaleducationprogram);
  • Numberofstudentseligibletoparticipateintheclinicaleducationprogram;
  • Specificdays,hoursandlocationsfortheclinicaleducationprogram;
  • Specificlearningobjectivesandperformanceexpectationsforstudents;
  • SpecificallocationofresponsibilitiesfortheWSUfacultyLiaison,andtheTrainingSiteclinicaleducationSupervisor,andothers,ifany,referencedelsewhereinthisAgreement;
  • Deadlinesandformatforstudentprogressreportsandevaluationforms.

AnysuchletteragreementswillbeconsideredtobeattachmentstothisAgreement,willbebindingonthePartieswhensigned by authorized representatives of eachparty,andmaybemodifiedbysubsequentletteragreementssignedbyauthorizedrepresentativesofeachparty.

b.WSUandTrainingSitewilljointlyplantheclinicaleducationprogramandjointlyevaluatestudents.Exchangeofinformationwillbemaintainedbyon-sitevisitswhenpracticalandbyletterortelephoneinotherinstances.

c.WSUandTrainingSitewillinstructtheirrespectivefaculty,staffandstudentsparticipatingintheclinicaleducationprogramtomaintainconfidentialityofstudent,client,andpatientinformationasrequiredbylawandbypoliciesandproceduresofWSUandTrainingSite.WSUshalldirectitstraineestocomplywiththepoliciesandproceduresofTrainingSite,includingthosegoverningtheuseanddisclosureofindividuallyidentifiablehealthinformationunderfederal law, specifically 45 CFRparts160and164.Solelyforthepurposeofdefiningthetrainees’roleinrelationtotheuseanddisclosureofTrainingSite’sprotectedhealthinformation,suchtraineesaredefinedasmembersoftheTrainingSite’sworkforce,asthattermisdefinedby45CFR160.103,whenengagedinactivitiespursuanttothisAgreement.However,suchtraineesarenotandshallnotbeconsideredtobeemployeesoftheTrainingSite.

d.Forstudentsinafull-timeeducationalexperience,WSUwillpayTrainingSiteoritsrepresentativeafeeofupto$60.00perstudent.Forstudentinapart-timeeducationalexperience,therewillbenopaymentoffeesbetweenWSUandTrainingSite.

e.Partieswillfollowallapplicablelaws,regulations,andpolicies.

f.StudentswhileengagedintheclinicallearningexperiencesprovidedpursuanttothisAgreementshallretainthestatusofstudentsworkingtowardsthefulfillmentoftheirdegreerequirements.StudentsarenotemployeesoragentsofWSU while soengaged.

2.WSU’S RESPONSIBILITIES

a.WSU willprovide,uponrequest,information toTraining SiteconcerningitscurriculumandtheprofessionalandacademiccredentialsofitsfacultyforthestudentsatTrainingSite.

b.WSU willdesignatean appropriatelyqualifiedand credentialedfacultymembertocoordinateandactastheLiaisonwithTrainingSite. WSUwillnotifyTrainingSiteinwritingofanychangeorproposedchangeofitsLiaison.

c.WSUwillberesponsibleforinstructionandadministrationofthestudents’academiceducationprogram,andwillhavethefinalresponsibilityforgradingstudents.

d.TheWSULiaisonwillmeetwiththeTrainingSiteclinicaleducationSupervisorPreceptorsatthebeginningandendoftheclinicaleducationprogramtodiscussandevaluatetheclinicaleducationprogram.Thesemeetingswilltakeplaceinpersonifpracticable,otherwisebytelephone conference. WSU is responsible for arrangingandplanningthemeetings.

e.WSUwillprovidethenamesandinformationpertainingtorelevanteducationandtrainingforallstudents enrolled in theclinicaleducation programtobe placed atTrainingSite,atleastfourweeksbeforethebeginningdateoftheclinicaleducationprogram.WSUisresponsibleforsupplyinganyadditionalinformationrequiredbyTrainingSiteassetforthinthisAgreement,priortothearrivalofstudents. WSU willnotifyTrainingSiteinwritingofanychangeorproposedchangeinastudent’sstatus.

f.WSUwillobtainevidenceofcurrentimmunizationsagainstdiphtheria,tetanus,poliomyelitis,measles(rubeola),mumps,rubella(orapositiverubellatiter),andofhepatitisBimmunizationstatusforthosestudentswhowillbeincontactwithpatients/clients.Foreachstudentbornafter1956,WSUwillmaintainonfilerecordsofpositivetiterorofpost-1967immunizationforrubellaandrubeola.Atthetimeofimmunization,studentswithnohistoryofexposuretochickenpoxwillbeadvisedtogetanimmunetiter.WSUwillrequireyearlypurifiedproteinderivative(ppd)tuberculosistestingorfollow-upasrecommendedifthestudentsareppd-positiveorhavehadbacillicalmettiguerin (BCG). WSU will provide, upon request,informationtoTrainingSiteregardingstudentstatusconcerningtheaboverequirements.

g.WSUwillassigntoTrainingSiteonlythosestudentswhohavesatisfactorilycompletedtheprerequisitedidacticportionofthecurriculumandwhohavecurrentcardio-pulmonaryresuscitation(CPR)certification.

h.WSUshallaskeachstudentwhomaybeplacedatTrainingSitetoobtainhis/hercriminalhistorybackgroundrecordfromtheWashingtonState Patrol, pursuant toRCW43.43.830andRCW43.43.838,andforpermissiontoreleaseacopyofthatrecordtoWSUandtoauthorizetheWSUtotransmitthatrecordor copy to theTrainingSite.WSUwillprovideTrainingSitewiththenamesofanystudentswhohavefailedtoprovidetherequestedrecordsorwhorefusetoauthorizethereleaseofrecordstoTrainingSite.Thestudentswillbeinformedthat,whetherornottheyagreetoobtaintherecordandagreetoreleaseittoWSUand the Training Site,TrainingSitemayconductthebackgroundinquirydirectly.TrainingSitemayrefuseplacement ofastudentwhodoesnotprovidethe requested records or who has arecordofpriorcriminalconduct.

TrainingSiteunderstandsandagreesthatanyinformationforwardedtoitbyWSUhasbeenprocuredthroughthisprocess.WSUdoesnotcertifytheveracityoftherecordsprovidedand,furthermore,theobligationtoconductappropriatebackgroundchecks and the liability fornon-compliance therewith remains the responsibility oftheTrainingSite.

i.WSUwillcomplywithandaskthatstudentscomplywiththepoliciesandproceduresestablishedbyTrainingSite.WSUwillnotifyeachstudentofhis/herstatusandresponsibilitiespursuanttothisAgreement.

j.WSUwillencourageeachstudentparticipatingintheclinicaleducationprogramtoacquirecomprehensivehealthandaccidentinsurancethatwillprovidecontinuouscoverageofsuch studentduring hisorherparticipationin theeducation program.WSUwillinformstudentsthattheyareresponsiblefortheirownhealthneeds,healthcarecosts,andhealthinsuranceandcoverage.

3.TRAINING SITE’S RESPONSIBILITIES

a.TrainingSitewillprovidestudentswithadesirableclinical education experiencewithinthescopeofhealthcareservicesprovidedbyTrainingSite.Trainingsitewilldesignateinwritingadministrators/preceptors,ifany,toberesponsiblefortheclinicaleducationprogram,andwilldesignateinwritingonepersonastheClinicalEducationSupervisor.TheClinicalEducationSupervisorwillmaintaincontactwiththeWSU-designatedLiaisontoassuremutualparticipationinandreviewof theclinicaleducationprogramandstudentprogress.TrainingSitewillsubmitinwritingtoWSUtheprofessionalandacademiccredentialsfortheadministrators/Preceptorsand/orClinicalEducationSupervisor.

b.TrainingSitewillprovidestudentswithaccesstosourcesofinformationnecessaryfortheeducationprogram,withinTrainingSite’spoliciesandproceduresandcommensuratewithpatients/clients’rights,includinglibraryresourcesandreferencematerials.

c.TrainingSitewillmakeavailabletostudentsbasicsuppliesandequipmentnecessaryforcareofpatients/clientsandtheclinicaleducationprogram. Withinthelimitationoffacilities,TrainingSitewillmakeavailableofficeandconferencespaceforstudentsand,ifapplicable,WSUfacultyandWSULiaison.

d.Trainingsitewillsubmitrequiredreportsoneachstudent’sperformanceand willprovideanevaluationtoWSUonformsprovidedbyWSU.

e.TrainingSiteretainsfullresponsibilityforthecareofpatients/clients,andwillmaintainthequalityofpatients/clientscarewithoutrelyingonthestudents’clinicaltrainingactivitiesforstaffingpurposes.

f.TrainingSitewillhavetherighttotakeimmediatetemporaryactiontocorrect asituationwhereastudent’sactionsendangerpatient’s/client’scare.Assoon aspossiblethereafter,TrainingSite’sclinicaleducationSupervisorwillnotifyWSUoftheactiontaken.Allfinalresolutionsofthestudent’sacademicstatusin suchsituationswillbemadesolelybyWSUafterreviewingthematterandconsideringwhateverwrittenfactualinformationTrainingSiteprovidesforWSU.However,TrainingSitereservestherighttoterminatetheuseofitsfacilitiesbyaparticularstudentwherenecessarytomaintainitsoperationfreeofdisruptionand to ensurequalityofpatientcare.

g.Onanydaywhenastudentisparticipatingintheclinicaleducationprogramatitsfacilities,TrainingSitewillprovidetosuchstudentnecessaryemergencyhealthcareorfirstaidforaccidentsoccurringinitsfacilities.Financialresponsibilityforsuchemergencycare,includingcareasdescribedelsewhereinthisAgreement,willbeasfollows:

  • TrainingSitereservestherighttobillstudentsforthecostofinitialfirst-aidcare.
  • Atthestudent’sexpense,TrainingSitemayprovidefollow-upcare,testingandcounseling,includingHIVtesting,andcounselingassociatedwiththattesting,intheabsenceofanysimilar service being immediately availablefromWSU’shealthservices.

h.ExceptasprovidedinthisAgreement,TrainingSitewillhave no obligation tofurnishmedicalorsurgicalcaretoanystudent.

i.TrainingSiteshallconsiderthatstudentsarelearnersandwillnotreplaceTrainingSitepersonnelwithstudents.Anyservicerenderedbystudentsisincidentaltotheeducationalpurposeoftheclinicaleducationprogram.

j.TrainingSiteshallrequirestudentsto adhere to the standards, policies, andregulationsofTrainingSiteduringtheirclinicaleducationprogram.

k.TrainingSiteshallrequirestudentstowearappropriateattireandnametags,andtoconformtothestandardsandpracticesestablishedbyWSUduringtheirclinicaleducationprogramatTrainingSite.

l.TrainingSiteunderstandsstudentsassignedtoTrainingSitewillbeandwillremainstudentsofWSU,andwillinnosensebeconsideredemployeesofTrainingSite.TrainingSitedoesnotandwillnotassumeanyliabilityforstudentsunderanylawrelatingtoWorkers’CompensationonaccountofthisAgreement,butmaychoosetocoverstudentsasvolunteersunderRCW51.12.035.StudentswillnotbeentitledtoanymonetaryorotherremunerationforservicesperformedbythematTrainingSite,norwillTrainingSiteotherwisehaveanymonetaryobligationtoWSUoritsstudentsbyvirtueofthisAgreement.

m.TrainingSitepersonnelparticipatingintheeducationalprogramprovidedpursuanttothisAgreementare,andshallremainemployeesoftheTrainingSiteforallpurposes,andshallnotbedeemedorconsideredtobeemployeesoragentsofWSU.

4.LIABILITYCOVERAGEPROVISIONS

a.EachPartytothisagreementwillberesponsibleforthenegligentactsoromissionsofitsownemployees,officers,oragentsintheperformanceofthisAgreement.NeitherPartywillbeconsideredtheagentoftheother,andneitherPartyassumesanyresponsibilitytotheotherPartyfortheconsequencesofanyactoromissionofanyperson,firm,orcorporationnotapartytothisAgreement.

b.WSUanditsofficers,employees,andagents,whileactingingoodfaithwithinthescopeoftheirofficialWSUduties,arecoveredbytheStateofWashingtonSelf-InsuranceProgramandtheTortClaimsAct(RCW4.92.060etseq.),andsuccessfulclaimsagainstWSUanditsemployees,officers,andagentsintheperformanceoftheirofficialWSUdutiesingoodfaithunderthisAgreementwillbepaidfromthetortclaimsliabilityaccountasprovidedinRCW4.92.130.

c.TrainingSitemaintainsprofessionalliabilitycoveragethatprovidesliabilitycoverageforitsemployees,officers,andagentsintheperformanceof this Agreement, andfurtherprovidesthemeansfordefenseandpaymentofclaimsthatmayariseagainstsuchindividuals.TrainingSiteshallprovideproofofsuchinsurancetoWSUuponrequest.

d.TrainingSitewillacceptplacementofonlythosestudentswhoareinsuredagainstliability for actions or inactions occurring in the clinical setting. Students participatinginthe clinicaleducationprogramwill be coveredeither bya studentmedicalmalpracticepolicyofferedthroughWashingtonStateUniversity,oracquiredbythestudentthroughanothersource.Thelimitsofsuchcoverageshallbe,ataminimum,$1,000,000 per occurrence. Certificates of such coverage purchased bythestudentwillbeprovidedtoTrainingSiteuponrequest.ShouldproofofinsurancenotmeetwithTrainingSite’sapprovalandsatisfaction,TrainingSitecanrefusetoacceptanystudentforplacement.

5.TERMANDTERMINATION

a.ThisAgreementiseffectiveuponexecutionbythePartiesandwillcontinuethereafterfromacademicyeartoacademicyearunlessterminatedasprovidedinthisAgreement.However,PartiesshallreviewthisAgreementnolaterthanthreeyearsfromitseffectivedateorearlierattherequestofeitherparty.

b.WSUandTrainingSitewilljointlyplanstudentplacementinadvanceofthebeginningofeachacademicyear,takingintoaccounttheneedsof the WSU forclinicalplacement,themaximumnumberofstudentsforwhomTrainingSite canprovideadesirableclinicaleducationexperience,andtheneedsofotherdisciplinesrequestingclinicalplacements.

c.ThisAgreementmaybeterminatedbyeitherPartybyoneyear’swrittennoticetotheotherParty.However,suchterminationshallnotbecomeeffectiveforthestudentsthenenrolledintheclinicaleducationprogramatTrainingSite,ifsuchterminationpreventsthecompletionoftherequirementsfortheirclinicaleducationprogram.

6.PROVISIONSREGARDINGBLOOD-BORNEPATHOGENS

a.WSUcertifiesithastrainedeachstudentitsendstoTrainingSiteinuniversalprecautionsandtransmissionofblood-bornepathogensanditwillsendtoTrainingSiteonlystudentswhohavebeentrainedinandhavepracticedusinguniversalprecautions.TrainingSitewillprovidepersonalprotectionequipmentthatisappropriatefortasksassignedtoWSU’sstudents.

b.Intheeventastudentsustainsaneedle-stickinjuryorothersubstantialexposuretobodilyfluidsofanotherorotherpotentiallyinfectionsmaterialwhileparticipatingintheclinicaleducationprogramatTrainingSiteagreestoprovidethefollowingservices:

  • Being seen by Training Site’s employee heath service and/or emergencydepartmentassoonaspossibleaftertheinjury;
  • Emergencymedicalcarefollowingtheinjury;
  • InitiationofHBV,HepatitisC(HCV)andHIVprotocol;
  • HIVcounselingandappropriatetesting.

c.TrainingSiteshalldeterminethesourcepatient’sHBV,HCVandHIVstatusintheusualmannertotheextentpossible.TrainingSitedoesnotacceptliabilityforanyillnessorinjurysubsequenttosuchaccidentalexposure,exceptasotherwiseprovidedinthisAgreement.

7.ENTIRE AGREEMENT

ThisAgreementandanyamendmentattachedheretoconstitutetheentireagreementbetweenthePartiesandsupersedeanyandallpriororalorwrittenagreements,commitments,orunderstandingsconcerningthemattersprovidedforinthisAgreement.Nootherunderstandings,oralorotherwise,regardingthesubjectmatterofthisagreement shall bedeemedtoexistortobindanyofthepartieshereto.

8.MODIFICATION

ThepartiesmaymodifythisAgreementonlybyasubsequentwrittenAgreementexecutedbytheParties.Anymodificationshallbeeffectiveonlyifwritten,signedanddatedbytheauthorizedrepresentativesofeachPartyandattachedtothisAgreement.

9.ORDEROFPRECEDENCE

AnyconflictorinconsistencyinthisAgreementandits attachments will be resolved bygivingthedocumentsprecedenceinthefollowingorder:

a.ThisAgreement;

b.AttachmentstothisAgreementinreversechronologicalorder.

10.GOVERNANCE

ThiscontractisenteredintopursuanttoandundertheauthoritygrantedbythelawsofthestateofWashington.TheParties’rightsorobligationsunderthisAgreementshall beconstruedinaccordancewiththoselaws. Theprovisionsofthisagreementshallbeconstruedtoconformtothoselaws.

11.NOTICES

Allnotices,demands,requests,orothercommunicationsrequired to be given or sent byWSUorTrainingSite,willbeinwritingandwillbemailed by first-class mail, postageprepaid,ortransmittedbyhanddeliveryorfacsimile,addressedasfollows:

For WSU:
Name: Leslie Power
Title: Off-Campus Program Director
Department: Speech & Hearing Sciences
Address: P.O. Box 1495
310 Riverpoint Blvd.
Spokane, WA 99210-1495
Phone: 509-358-7592
Fax: 509-358-7600
E-mail: / For Training Site:
Name:
Title:
Department:
Address:
Phone:
Fax:
E-mail:

Eachpartymaydesignateachangeofaddressbynoticeinwriting. Allnotices,demands,requestsorcommunicationsthatarenothanddeliveredwillbedeemedreceivedthree(3) daysafterdepositintheU.S.mail,postageprepaid;oruponconfirmationof successfulfacsimile transmission.

13.SURVIVAL

WSUandTrainingSiteexpresslyintendandagreethattheliabilitycoverageprovisionsofthisAgreementwillsurvivetheterminationofthisAgreementforanyreason.

14.SEVERABILITY

IfanyprovisionofthisAgreementoranyprovisionofanydocumentincorporatedbyreference,oranyotheragreementdocumentorwritingpursuanttoorinconnectionwiththisAgreement,shallbeheldwhollyorpartiallyinvalidorunenforceableunderapplicablelaw,suchinvalidityshallnotaffecttheotherprovisionsofthisAgreementwhichcanbegiveneffectwithouttheinvalidprovision,ifsuchremainderconformstotherequirementsofapplicablelawandthefundamentalpurposeofthisagreement,andtothisendtheprovisionsofthisAgreementaredeclaredtobeseverable.

15.WAIVER

AfailurebyeitherpartytoexerciseitsrightsunderthisagreementshallnotprecludethatpartyfromsubsequentexerciseofsuchrightsandshallnotconstituteawaiverofanyotherrightsunderthisAgreementunlessstatedtobesuchinawritingsignedbyanauthorizedrepresentativeofthepartyandattachedtothisagreement.

16.INSPECTION

TrainingSite will permit, onreasonablenotice andrequest, theinspectionofclinical andrelatedfacilitiesbyagencieschargedwithresponsibilityforaccreditationofWSU.

17.HIPAA

UniversityshalldirectitsstudentstocomplywiththepolicyandproceduresoftheTrainingSite,includingthosegoverningtheuseanddisclosureofindividuallyidentifiablehealthinformationunderfederallaw,specifically45CFRparts160and164. Solely for thepurposesofdefiningthestudents’roleinrelationtotheuseanddisclosureofTrainingSite’sprotectedhealthinformation,asthattermisdefinedin45CFRparts 160 and 164, thestudentsaredefinedasmembersoftheTrainingSite’sworkforce,asthattermisdefinedby45CFR160.103,whenengagedinactivitiespursuanttothis Agreement. However, thestudentsarenotandshallnotbeconsideredtobeemployeesorvolunteersoftheTrainingSite,norarethestudentsagentsoftheTrainingSitebyvirtueofthisprovision.

18.NON-DISCRIMINATION

EachpartycertifiesthatitwillnotdiscriminateintheperformanceofthisAgreementonthebasisofrace,color,nationalorigin,gender,sexualorientation(toincludegenderidentity),religion,veteranormilitarystatus,orthepresenceofanysensory,mentalorphysicaldisabilityortheuseofatrainedguidedogorserviceanimalbyapersonwithadisability,incompliancewith(a)PresidentialExecutiveOrder11246,asamended,includingtheEqualOpportunityClausecontainedtherein;(b)Section503oftheRehabilitationActof1973,as amended,andthe VietnamEra VeteransReadjustmentActof1974,asamended,and theAffirmativeActionClausescontainedtherein;(c)the Americans with Disabilities Act of1990,asamended;and(d)Washingtonstatecivilrights and nondiscrimination laws. Thepartiesfurtheragreetheywillnotmaintainfacilitieswhicharesegregatedonthebasisofrace,color,religionornationaloriginincompliancewith Presidential Executive Order11246,asamended,andwillcomplywiththeAmericanswithDisabilitiesActof1990,asamended,regardingprograms,services,activitiesandemploymentpractices.

19.SIGNATURES

ThePartiesexecutingthisAgreementbelowherebycertifytheyhavetheauthoritytosignthisAgreementonbehalfoftheirrespectivePartiesandthatthePartiesagreetothetermsandconditionsofthisAgreementasshownbythesignaturesbelow.

[Signatures follow on next page.]

FORWASHINGTONSTATEUNIVERSITY:FORTRAININGSITE:

Approvedby:Approved by:

Gail D. Chermak, Ph.D.Name:

Chair, Speech and Hearing Sciences DepartmentTitle:

Date:Date:

Recommended by:

Leslie Power

Off-Campus Program Director

Date:

SHS Model Medical Student Affiliation TemplatePage 1 of 10

Last Revised: 8/19/2014