THIS AGREEMENT made in duplicate as of the day

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THIS AGREEMENT made in duplicate as of the day Powered By Docstoc
					                    Instructions for Placement Agreement for Clinical Practicum

Please insert the applicable information in designated areas as follows:

Date Line - 1st Tab:                       Insert the day

Date Line - 2nd Tab:                       Insert the month

Date Line - 3rd Tab:                       Insert the year

Name of other party - 4th Tab:             Insert full legal name of the Field Placement Site

Preamble - 1st Tab:                        Identify discipline (i.e. Pharmacy)

Section 1 - 1st Tab:                       Insert month and day when the Agreement will begin

Section 1 - 2nd Tab:                       Insert year when the Agreement will begin

Section 1 - 3rd Tab:                       Insert month and day when the Agreement will end

Section 1 - 4th Tab:                       Insert year when the Agreement will end

Section 2 (a):                             Insert the position of the liaison for the Placement Site

Section 2 (b):                             Insert the position of the liaison for the University

Section 17:

         1st Tab:                          Insert the name of the Field Placement Site

         2nd Tab:                          Insert the street address of the Field Placement Site

         3rd Tab:                          Insert the City, Province and Postal Code (in that order) of the Field
                                           Placement Site

         4th Tab:                          Insert the name of the Department within the University for notice
                                           purposes

         5th Tab:                          Insert the building/ address for the Department within the University
                                           for notice purposes

         6th Tab:                          Insert the City, Province and Postal Code (in that order) for the
                                           Department within the University for notice purposes
Signature Line:

         1st Tab:                          Insert the title of University signing authority (ie. Dean, Faculty of
                                           Pharmacy)

         2nd Tab:                          Insert full legal name of Field Placement Site (should be the same as
                                           at the outset of Agreement)

         3rd Tab:                          Insert title of Field Placement Site’s signing authority (if known)

         4th Tab:                          Insert title of Field Placement Site’s second signing authority (if
                                           known and if applicable)
                                               -2-

Routing –please also see: http://umanitoba.ca/admin/vp_admin/legal/media/signing_policy.pdf

1.     forward the completed Agreement to the appropriate Dean or Director for signature, ensuring
       that a sufficient number of copies of the Agreement are signed so that each party who will be
       signing the Agreement may keep an original copy.

2.     arrange for the other party to sign the Agreement.

3.     Once all signatures are obtained, provide one original copy to each party. The University’s
       copy must be forwarded to the Office of Legal Counsel for filing in the University’s central
       contracts vault. A photocopy of the Agreement should be kept for your records.
THIS AGREEMENT made in duplicate as of the                    day of       , 20      .

BETWEEN:

                                 THE UNIVERSITY OF MANITOBA
                                        (the “University”)

                                                   - and -


                                        (the “Field Placement Site”)


WHEREAS it is in the interests of the University and the Field Placement Site that the development of
in Manitoba be furthered through the educational preparation of the students of the University by way of
clinical experience at the Field Placement Site.

NOW THEREFORE this Agreement witnesseth that in consideration of the mutual covenants herein contained
the parties hereto agree that:

1.     This Agreement shall commence on             , 20         and end on       , 20       .

2.     Liaison between the University and the Field Placement Site shall be by and through the following
       persons:

       (a)     on behalf of the Field Placement Site, the        , or such other individual as the Field
               Placement Site may delegate from time to time; and,

       (b)     on behalf of the University, the              , or such other individual as the University may
               delegate from time to time;

       (collectively referred to as the “Liaison”). The Liaison will consult by telephone on a regular and
       planned basis.

3.     The University shall notify the Field Placement Site that the University has approved each clinical
       practicum proposal developed by a University student in consultation with an academic advisor and
       the Field Placement Site (the “Clinical Practicum”).

       Changes may not be made to any University approved Clinical Practicum without the University’s
       prior approval.

4.     The Field Placement Site will plan and conduct a period of orientation to the Field Placement Site for
       the students prior to the commencement of each Clinical Practicum. It is contemplated that the
       orientation period will include the presentation of selected current policies, regulations and procedures
       of the Field Placement Site.
                                                      -2-


5.      The University acknowledges the importance of confidentiality of personal health information in
        accordance with The Personal Health Information Act (Manitoba)(the “Act”) and patient privacy
        laws. In compliance with its obligations under the Act, the Field Placement Site will, as part of its
        orientation program, distribute and explain to the students, a confidentiality pledge in such form and
        content as may be appropriate, in accordance with the Act. The Field Placement Site shall maintain
        the confidentiality pledges within its record as evidence of its compliance with the Act.

        The University shall not be liable in any manner for a failure or omission by the Field Placement Site
        to comply with its obligations under the Act in connection with the form, content or execution of the
        confidentiality pledges, or any other related or other matter under the Act.

6.      The Field Placement Site will provide for the undergraduate students of the University, without charge
        to the University, such facilities at the Field Placement Site as are reasonable and appropriate, lockers
        or change rooms, access to cafeteria and/or eating room, class and/or conference rooms, use of a
        library and parking space (to be provided free only if no parking charge is made to other persons).

7.      The Field Placement Site shall be responsible for:

        (a)      instruction and supervision of student(s) during each Clinical Practicum;

        (b)      such evaluation and reports as required by the University.

As students under The Workers Compensation Act (Manitoba) (the “Workers Compensation Act”) students
        engaged in the Clinical Practicum are covered for injuries in accordance with and subject to the
        provisions of the Workers Compensation Act. In the event of an injury during the Clinical Practicum,
        the Field Placement Site Liaison should promptly contact the University Liaison to ensure that a report
        and claim can be made to the Workers Compensation Board.

        Where the location of the Field Placement Site is outside of the Province of Manitoba, and students
        engaged in the Clinical Practicum are not resident in Manitoba, the University makes no representation
        as to workers compensation coverage in place.

The University shall indemnify and save harmless the Field Placement Site and its officers, servants and agents
       from every action, suit or claim in respect of any injury, loss or damage resulting from the negligent
       acts or omissions by the University, its officers or servants, when acting within the scope of their
       employment or by the undergraduate students when acting within the scope of the Clinical Practicum,
       except to the extent that injury, loss or damage is caused by the act or omission of the Field Placement
       Site, or any of its officers, servants or agents.

The Field Placement Site shall indemnify and save harmless the University and its officers, servants and agents
        from every action, suit or claim in respect of any injury, loss or damage resulting from the negligent
        acts or omissions by the Field Placement Site, its officers or servants, when acting within the scope of
        their employment, except to the extent that injury, loss or damage is caused by the act or omission of
        the University, or any of its officers, servants or agents, or by students acting within the scope of the
        Clinical Practicum.
                                                     -3-


This Agreement may be terminated any time by either party giving four (4) clear months written notice to the
       other party, provided, however, that any scheduled Clinical Practicum will not be terminated prior to
       completion by the student(s) of the said Clinical Practicum (except where just cause exists in relation
       to any individual student’s conduct during the corresponding Clinical Practicum).

The parties may amend any provision of this Agreement at any time upon mutually so agreeing in writing.

13.     The Field Placement Site shall, in keeping with its responsibilities to its clients, have the
        right to intervene in those instances where a student may be functioning in a manner
        considered to be of potential risk to the well-being of the client or contrary to the regulations,
        rules, policies or procedures of the Field Placement Site. In such event, the University shall
        withdraw a student from a Clinical Practicum if requested by the Field Placement Site.

14.     The Field Placement Site shall not, without obtaining the prior written consent of the University,
        assign or transfer this Agreement or any interest herein.

15.     Sections 5 (if applicable), 9 and 10 shall survive termination of this Agreement.

16.     This Agreement shall be construed in accordance with the laws of Manitoba as applied to
        transactions taking place entirely within Manitoba between Manitoba residents.

17.     All notices to be given by either party to the other under this Agreement shall be delivered or mailed
        by registered or certified post, postage prepaid, addressed to such other party respectively as follows:

        If to the Field Placement Site:




        If to the University:
                                                                                      -4-


18.          This Agreement may be executed in any number of counterparts and by different parties in
             separate counterparts, each of which when so executed shall be deemed to be an original and
             all of which taken together shall constitute one and the same agreement. Delivery by
             facsimile or by electronic transmission in portable document format (PDF) of an executed
             counterpart of this Agreement is as effective as delivery of an originally executed counterpart
             of this Agreement.

IN WITNESS WHEREOF the parties have hereto executed this Agreement as of the day and year first above
written.

                                                                                  THE UNIVERSITY OF MANITOBA


                                                                                  Per:
                                                                                                Title:




                                                                                  Per:
                                                                                                Title:


                                                                                  Per:
                                                                                                Title:

F:\LEGAL OFFICE\Precedents\Website Documents\Signing Policy\Field Placement Site Agreement (Clinical) March 2010.doc