Affiliation Agreement

Document Sample
Affiliation Agreement Powered By Docstoc
					         Form Final: 7/8/08                                   CLINICAL PLACEMENT ATTESTATION FORM - Clinical Placement Pilot                                                                           1 of 1

Name of School: _________________________________________________________________________ Course Number: ___________________________
Name of Clinical Agency for Placement: ____________________________________________________ Name of Course:___________________________
Dates for Clinical Placement: (Start/End) _______________________________________________ Days of the Week/Shift: ___________/______________
Units for Clinical Placement: _______________________________________________________________
This form is to be completed for each clinical group of students in the agency.
Items marked with an "X" or expiration date below have a document on file at the School / Mark "N/A" if item not a requirement on the affiliation agreement.
                                                                                                                                                                                   Computer
                                                                                                 BLS/                                                             Month/Day of     Training
                                               Negative   Profic.      TB                        CPR                                Negative Drug Clinical Agency Birth for        /Access ID
Student Roster - Full Name with Middle Initial Background Written &    PPD/                      Exp. Physical                      Screen and/or Orientation     Computer         information
and Current Contact Information (Phone/Email) Check       Oral English X-Ray MMR Varicella Hep B Date Exam                          Waiver        Scheduled       Access           (last 4 digits)




                                                                                                                                                                                   Computer
                                                                                                         BLS/                                                       Month/Day of   Training
Clinical Instructor Full Name and Middle               Negative   Profic.      TB                        CPR Physical     Negative Drug Clinical Agency             Birth for      /Access ID
Initial and Contact Information                        Background Written &    PPD/                      Exp. Exam/       Screen and/or Orientation                 Computer       information       Computer
(Phone/Pager/Cell and Email)                           Check      Oral English X-Ray MMR Varicella Hep B Date Attestation Waiver        Scheduled                   Access         (last 4 digits)   Training



Course Instructor Contact Information:
Phone:                                                                            Pager:                                Cell:
Email:
As per our affiliation agreement, the school has in place Malpractice Insurance, Worker's Compensation and has established lawful presences
in the United States for all students and faculty.
All of the above have also completed the required: HIPAA/Confidentiality; Safety and Bloodbourne Pathogen; and Cultural Diversity Training and Competency Testing
While in the clinical agency, all students and school representatives will display a Photo ID Badge.

Form Completed by: ____________________________________________                                                         Date Completed: _____________________________________
Phone Number:                                                                                                           Email Address:
Back-up at the School Name: _____________________________ Title:______________________ Phone:_________________________
email:_____________________________________________________________
Director/Dean Signature:____________________________________________________ Date: _____________________________________________
*4/8/09 Approved by the Standards Sub-Committee /*4/9/08 - Form endorsed by the ACE Services and Education Sub-Committee to replace the required "Attestation Letter and Student Roster."
Final Approval by the Clinical Placement Oversight Committee 5/19/08 for acceptance and use with all Pilot Partners -- Taken to ACE July/2008

				
DOCUMENT INFO
Description: Affiliation Agreement document sample