Phyllis Horns, RN, DSN, FAAN. Medical Director Approval: Todd Beste, MD

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1 The Brody School of Medicine and ECU Physicians Group Practice Policy and Procedure Manual Topic: Student Training and Professional Visitor Policy - #A31 Section No. 1 Approval Date: Section Name: Administrative and Clinical Operations Dean Approval: Phyllis Horns, RN, DSN, FAAN Medical Director Approval: Todd Beste, MD I. Purpose: The purposes of this policy are to (1) define which students and professional visitors have requirements that must be met prior to beginning an educational experience in The Brody School of Medicine (BSOM) or ECU Physicians Group Practice, (2) define the requirements, and (3) outline the process to ensure that those requirements have been met. II. III. IV. Policy: It is the policy of BSOM and the ECU Physicians Group Practice to promote and support educational experiences for students and professional visitors but also to ensure compliance with applicable regulations and internal policies to protect all parties. The requirements set forth in this policy and procedure must be met prior to beginning any educational experiences. Some BSOM requirements can be satisfied with documentation that the requirement was met from another institution. Individual students, as defined in Article IV(C), will not be allowed to handle sharps, infectious or radioactive materials, hazardous chemicals or have physical contact with laboratory animals. Visitors subject to this policy must meet the requirements of this policy and procedure prior to beginning any educational experience. Reciprocity for OSHA blood borne pathogen and tuberculosis training from another institution completed within the previous 12 months may be accepted. Policy Exclusions: This policy does NOT apply to the following individuals or groups of individuals: medical school applicants, applicants for employment at BSOM, guest lecturers for educational presentations that are limited to the classroom and do not involve patient care or laboratory work or educational program attendees. Adjunct, Affiliate and Paid Faculty appointees are NOT subject to this policy. Definitions A. Student From Formally Affiliated Programs - a student enrolled in an educational institution or agency other than ECU, with which BSOM maintains a formal contractual affiliation under the Universal Affiliation Agreement, for the purpose of obtaining a degree, license or certificate. Examples are Pitt County Community College and Campbell University s School of Pharmacy. B. Student From Formal Enrichment Programs a student enrolled in a formal enrichment program endorsed by BSOM. Types of students in this category would include, but not necessarily be limited to: Summer Ventures, Honors Med, Health Occupation Student Association, Health Careers Investigation and Immersion, Summer Program for Future Effective Date: Revision/Review Date: Contact Person/Reference Source: Extension: ECU Physicians Group Practice, Director of Nursing Practice Office of Generalist Program Office of Academic and Faculty Development Revision/Review Person/ Source: Page 1 of 10

2 The Brody School of Medicine and ECU Physicians Group Practice Policy and Procedure Manual Topic: Student Training and Professional Visitor Policy - #A31 Section No. 1 Approval Date: Section Name: Administrative and Clinical Operations Dean Approval: Phyllis Horns, RN, DSN, FAAN Effective Date: Medical Director Approval: Todd Beste, MD Agreement is executed by the educational institution or agency and Brody School of Contact Person/Reference Source: Extension: ECU Physicians Group Practice, Director of Nursing Practice Office of Generalist Program Office of Academic and Faculty Development Revision/Review Person/ Source: Page 2 of 10 Revision/Review Date: Doctors, Summer Venture Into Health Careers, and ECU Undergraduate Shadowing Program. C. Individual Student a student in high school, trade school, or institutions of higher learning who desires an educational experience in healthcare or research at the BSOM and does not fall into Article IV (A) nor (B) above and should be considered as an observer. D. Medical Student a medical student who is enrolled in a medical school at another accredited institution and requests a rotation at BSOM for additional experiences. E. Professional Visitor a licensed or other credentialed healthcare provider or educator who seeks an educational experience such as for training and/or observation but is not seeking a BSOM faculty appointment. BSOM faculty appointments are managed by the Health Sciences Personnel Administration. V. Failure to Comply A. Involved employees and/or Sponsoring Departments failing to comply with this policy may be subject to appropriate disciplinary action under applicable University policies. VI. B. Students and Professional Visitors who are subject to this policy and fail to comply with its requirements will be considered as unauthorized persons. 1. An unauthorized person accepts full responsibility for any uses of University properties and agrees to make full restitution with regards to any compensation required as a result of his/her use, misuse or damage to such properties. 2. An unauthorized person also accepts full responsibility for any consequences for violating this policy including, but not limited to, all liability whatsoever which result from the actions caused by the unauthorized person and not from causes beyond East Carolina University and its employees control or negligence. 3. BSOM reserves the right to ask that the unauthorized person to immediately leave the premises and have his/her learning experience terminated. Procedure: No one will be allowed to work or participate in educational experiences without complying with these policies. Some requirements may be satisfied if the student and/or professional visitor can submit evidence of compliance from another institution. A. Students From Formally Affiliated Programs - Students training in the BSOM for the purpose of fulfilling requirements at another institution for a degree or to become licensed or certified are covered by the Universal Affiliation Agreement (Attachment 1). The

3 The Brody School of Medicine and ECU Physicians Group Practice Policy and Procedure Manual Topic: Student Training and Professional Visitor Policy - #A31 Section No. 1 Approval Date: Section Name: Administrative and Clinical Operations Dean Approval: Phyllis Horns, RN, DSN, FAAN Effective Date: Revision/Review Date: Medical Director Approval: Todd Beste, MD Medicine. The agreement is not generally executed for an individual student. Examples include clinical students from Pitt County Community College and other learning institutions. 1. ECU Physicians Group Practice/Director of Nursing Practice or designate will be the office of primary responsibility to ensure accurateness and completeness of this process and to coordinate with others within BSOM and Division of Health Sciences responsible for maintaining contracts. 2. The department receiving the request to become a training site/location is responsible to ensure that the Agreement has been executed in a timely fashion prior to the commencement of any training for students from the entity. 3. It is the institutional education or agency s (Formally Affiliated Program) responsibility to (1) maintain and submit evidence that any student authorized by the Agreement has been properly vaccinated and screened for certain infections, (2) procure and maintain adequate professional liability insurance and (3) provide the student with instructions on Infection Control, Blood-borne Pathogens, Tuberculosis, Substance Abuse Prevention and OSHA Workplace Standards. (Appendix B of the Universal Affiliation Agreement.) 4. HIPAA Training specific to BSOM will be provided by BSOM. It must be completed prior to the beginning of the on-site training experience and can be accomplished on-line. The on-line address is given to the entity for its students use. 5. Department-specific training will be conducted and documented by the department s designated staff. Department-specific training might include but not be limited to a unit orientation, review of emergency procedures and evacuation plans, location and review of Hazard Communication (MSDS) Policy, and documentation standards, etc. 6. BSOM reserves the right to audit the program at any time to ensure compliance with the terms of the agreement. 7. When students are training in any BSOM facility or program, they will wear an identification badge at all times. B. Students From Formal Enrichment Programs and Individual Student are different by definition but have the same requirements that must be met prior to beginning their educational experience at BSOM. 1. The Office of Generalist Program has the primary responsibility for student visitors in these categories, to respond to questions, assist with ensuring that appropriate forms are completed, and for maintaining individual student files once the educational opportunity has been completed. Contact Person/Reference Source: Extension: ECU Physicians Group Practice, Director of Nursing Practice Office of Generalist Program Office of Academic and Faculty Development Revision/Review Person/ Source: Page 3 of 10

4 The Brody School of Medicine and ECU Physicians Group Practice Policy and Procedure Manual Topic: Student Training and Professional Visitor Policy - #A31 Section No. 1 Approval Date: Section Name: Administrative and Clinical Operations Dean Approval: Phyllis Horns, RN, DSN, FAAN Medical Director Approval: Todd Beste, MD a. Completed files should be retained for a period of no less than one year. b. Files should be destroyed in accordance with other governing policies to prevent inadvertent disclosure of personal identification or protected health information. 2. The Department or location where the experience is being requested will maintain a file on each individual visitor for the duration of the visitor s educational experience. When the experience has been completed, the file will be forwarded to the Office of the Generalist Program. 3. Student From Formal Enrichment Programs, as defined in Article IV(B), will be considered for training, observation and/or shadowing based on the individual student s objectives and ability of BSOM and/or ECU Physicians to meet the objectives. 4. Individual Student must first be approved by the Office of Generalist Program. Approval should be based on the individual s objectives for seeking the experience; the age and maturity of the individual, if under the age of 18; and ability to meet the objectives and accommodate the request. a. During any encounter with a patient or legally responsible party, the student must be introduced with informing the patient and/or responsible party of the status of the student; i.e., medical student, student nurse, pharmacy student, etc. The title of doctor or nurse or pharmacist should not be given to the student. The patient and/or responsible party must give consent for the student to be present. Consent can be verbal and should be noted in the medical record. b. The individual student should be considered as only an observer within the location of his/her educational experience. c. The individual student should not be asked to perform any procedures, handle any blood or body fluids or sharps, radioactive material nor hazardous chemicals. d. The individual student will not be allowed to have an educational experience in a research lab with pathogenic infectious agents or recombinant DNA due to the hazard level. e. The individual student should not be exposed to any patients with tuberculosis or serious airborne infectious diseases as the individual student would not be trained or fitted for personal protective equipment. 5. Before a student can be approved for an educational experience, the following must be completed by the potential visitor, and reviewed and approved by the Department Chair, Assistant or Associate Dean or designate, and Office of Generalist Program. Effective Date: Revision/Review Date: Contact Person/Reference Source: Extension: ECU Physicians Group Practice, Director of Nursing Practice Office of Generalist Program Office of Academic and Faculty Development Revision/Review Person/ Source: Page 4 of 10

5 The Brody School of Medicine and ECU Physicians Group Practice Policy and Procedure Manual Topic: Student Training and Professional Visitor Policy - #A31 Section No. 1 Approval Date: Section Name: Administrative and Clinical Operations Dean Approval: Phyllis Horns, RN, DSN, FAAN Effective Date: Revision/Review Date: Medical Director Approval: Todd Beste, MD a. Visitor Encounter Application (Attachment 2); b. If the visitor experience is for a period less than 14 days, the Short Term Visitor Health Questionnaire must be completed (Attachment 3). 1) If any questions on the Health Questionnaire are answered in the affirmative, the visitor s application will be denied with the following exceptions. (a) Pregnant visitors may be considered for the educational experience depending upon the location and type of experience, exposure to teratogenic agents, etc. (b) Visitors with latex allergies may be considered for the educational experience depending upon the location and type of experience, availability of non-latex supplies, and severity of the sensitivity (consult with Prospective Health). 2) The application may be considered in the future: (a) after evaluation by a licensed medical professional rules out the presence of an infectious condition, which is certified in writing; or (b) after 1-2 weeks have passed and the condition of all concern resolves and all questions on the Health Questionnaire are answered in the negative. 3) The Office of Prospective Health may be consulted by the department if there are any questions. c. If the visitor experience is for a period greater than 14 days, the Long Term Visitor Immunization History must be completed. (Attachment 4); d. BSOM Assumption of Risk and Release Form (Attachment 5); If the individual is under the age of 18, a parent or legal representative must also sign the Visitor Encounter Agreement and Release and Waiver from Liability Form. e. BSOM Code of Conduct Attestation Form (Attachment 7). f. Once the visitor has been approved for an educational experience BUT before the visitor can begin the experience in that location, prerequisite training must be completed with documented evidence. Reciprocity for OSHA blood borne pathogen and tuberculosis training from another institution completed within the previous 12 months may be accepted. Department-specific orientation should include BSOM specific information on use of PPE, and how to manage an exposure. The Contact Person/Reference Source: Extension: ECU Physicians Group Practice, Director of Nursing Practice Office of Generalist Program Office of Academic and Faculty Development Revision/Review Person/ Source: Page 5 of 10

6 The Brody School of Medicine and ECU Physicians Group Practice Policy and Procedure Manual Topic: Student Training and Professional Visitor Policy - #A31 Section No. 1 Approval Date: Section Name: Administrative and Clinical Operations Dean Approval: Phyllis Horns, RN, DSN, FAAN Medical Director Approval: Todd Beste, MD prerequisite training is dependent upon the type of student visitor and location of the experience. Training prerequisite and evidence of compliance worksheet is in Attachment 2. Training may include but not necessarily limited to: Bloodborne Pathogen and Tuberculosis training; BSOM HIPAA Privacy training if student will have access to any patient information in any form oral, written, or electronic. Use of personal protective equipment; Hazardous materials precautions (MSDS); and Registration with Radiation Safety, if there will be any contact with radioactive material or radiation exposure. Department-specific training will be conducted and documented by the department s designated staff. Department-specific training might include but not be limited to a unit orientation, review of emergency procedures and evacuation plans, location and review of MSDS information, and documentation standards, etc. Animal Care and Use Training is site and institution specific and is required at ECU regardless of previous training elsewhere. 6. A BSOM visitor identification badge must be obtained and worn by the visitor at all times during the visiting/educational period. a. For student visitors who will be here less than 14 days, the Office of Generalist Program will issue a numbered visitor badge that must be worn by the visitor at all times during the visiting/educational period. b. For student visitor who will be here greater than 14 days, the student visitor will obtain a photo identification badge in the same manner as employees. The Office of the Generalist Program will complete the necessary request forms. c. When the educational experience has been completed, the badge must be retrieved from the individual and returned to the Office of Generalist Program with the individual s file. Other proper notification will be made according to the type of Identification Badge the visitor was issued. 7. The student will not wear a white coat or other attire which might encourage the assumption that he/she is a health professional. Effective Date: Revision/Review Date: Contact Person/Reference Source: Extension: ECU Physicians Group Practice, Director of Nursing Practice Office of Generalist Program Office of Academic and Faculty Development Revision/Review Person/ Source: Page 6 of 10

7 The Brody School of Medicine and ECU Physicians Group Practice Policy and Procedure Manual Topic: Student Training and Professional Visitor Policy - #A31 Section No. 1 Approval Date: Section Name: Administrative and Clinical Operations Dean Approval: Phyllis Horns, RN, DSN, FAAN Medical Director Approval: Todd Beste, MD C. Medical Student - Medical schools or individual medical students desiring a rotation at BSOM must contact the Office of Student Affairs ( ). The student(s) must be enrolled at an accredited medical school in the U.S. or Canada. (Only schools listed on the AAMC or AACOM websites are accepted). 1. Before the approval for an education experience, the medical student must complete the following forms. a. Visiting Student Application (Attachment 6). b. Immunization Record/History (Included in Attachment 2, Visiting Student Application). This form must be signed by an official from the home medical school c. Verification of Enrollment, Medical School Information (Included in Attachment 2, Visiting Student Application). This form must be signed by an official from the home medical school. d. BSOM Code of Conduct Attestation Form (Attachment 7). 2. The medical student must complete BSOM HIPAA Privacy training prior to the educational experience if she or she will have access to any patient information in any form oral, written, or electronic. 3. Office of Student Affairs is responsible for maintaining the necessary paperwork for each visiting medical student. a. Unless otherwise dictated by accrediting bodies, visiting medical student files will be maintained for a period of no less than one year. b. Files should be destroyed in accordance with other governing policies to prevent inadvertent disclosure of personal identification or protected health information. 4. When the visiting student has been accepted and presents to BSOM, he/she will comply with all applicable policies and procedures governing BSOM medical students. a. A photo identification card will be obtained from Pitt County Memorial Hospital and must be worn at all times while on duty. b. The student must be introduced to the patient and/or responsible party using the proper title of medical student. The student should never be called Doctor. The patient and/or responsible party must give consent to having the student present. 5. When the educational experience has been completed, the badge must be returned to Pitt County Memorial Hospital. Effective Date: Revision/Review Date: Contact Person/Reference Source: Extension: ECU Physicians Group Practice, Director of Nursing Practice Office of Generalist Program Office of Academic and Faculty Development Revision/Review Person/ Source: Page 7 of 10

8 The Brody School of Medicine and ECU Physicians Group Practice Policy and Procedure Manual Topic: Student Training and Professional Visitor Policy - #A31 Section No. 1 Approval Date: Section Name: Administrative and Clinical Operations Dean Approval: Phyllis Horns, RN, DSN, FAAN Effective Date: Revision/Review Date: Medical Director Approval: Todd Beste, MD D. Professional Visitor - a licensed or other credentialed healthcare professional or educator who is seeking an educational experience such as for training and/or observation but is not seeking a BSOM faculty appointment. BSOM faculty appointments are managed by the Health Sciences Personnel Administration. 1. The Office of Academic and Faculty Development has the primary responsibility for managing this type of visitors, to respond to questions, assist with ensuring appropriate forms are completed, and for maintaining individual professional visitor files once the educational opportunity has been completed. a. Completed files should be retained for a period of no less than one year. b. Files should be destroyed in accordance with other governing policies to prevent inadvertent disclosure of personal identification or protected health information. 2. The Department or location where the experience is being requested will maintain a file on each individual visitor for the duration of the visitor s educational experience. When the experience has been completed the file will be forwarded to the Office of Academic and Faculty Development. 3. Professional Visitors must first be approved by the individual Department Chair, Associate Dean or designate. Approval should be based on the individual s objectives for seeking the experience and ability to meet the objectives and accommodate the request. 4. The licensed and credentialed professional visitor must comply with the ECU Physicians Credentialing Program and policies governing a visiting credentialed professional. a. ECU Physicians Group Practice is responsible for the approval process of visiting credentialed professionals. b. If the professional will also be training and/or observing in Pitt County Memorial Hospital, the hospital s policy for visiting credentialed professional must be followed. 5. Before a professional visitor can be approved for an educational experience, the following must be completed by the potential visitor, and reviewed and approved by the Department Chair, Associate Dean or designate and Office of Academic and Faculty Development. a. Visitor Encounter Application (Attachment 2); b. If the visitor experience is for a period less than 14 days, the Short Term Visitor Health Questionnaire must be completed (Attachment 3). Contact Person/Reference Source: Extension: ECU Physicians Group Practice, Director of Nursing Practice Office of Generalist Program Office of Academic and Faculty Development Revision/Review Person/ Source: Page 8 of 10

9 The Brody School of Medicine and ECU Physicians Group Practice Policy and Procedure Manual Topic: Student Training and Professional Visitor Policy - #A31 Section No. 1 Approval Date: Section Name: Administrative and Clinical Operations Dean Approval: Phyllis Horns, RN, DSN, FAAN Medical Director Approval: Todd Beste, MD 1) If any questions on the Health Questionnaire are answered in the affirmative, the visitor s application will be denied with the following exceptions. (a) Pregnant visitors may be considered for the educational experience depending upon the location and type of experience, exposure to teratogenic agents, etc. (b) Visitors with latex allergies may be considered for the educational experience depending upon the location and type of experience, availability of non-latex supplies, and severity of the sensitivity (consult with Prospective Health). 2) The application may be considered in the future: (a) after evaluation by a licensed medical professional rules out the presence of an infectious condition, which is certified in writing; or (b) after 1-2 weeks have passed and the condition of all concern resolves and all questions on the Health Questionnaire are answered in the negative. 3) The Office of Prospective Health may be consulted if there are any questions. c. If the visitor experience is for a period greater than 14 days, the Long Term Visitor Immunization History must be completed. (Attachment 4); d. BSOM Assumption of Risk and Release Form (Attachment 5); Release and Waiver from Liability Form (Attachment 5) must be signed. Professional Visitors who are independent licensed providers will need to demonstrate evidence of adequate professional liability insurance with a certificate of insurance. e. BSOM Code of Conduct Attestation Form (Attachment 7). f. Once the visitor has been approved for an educational experience BUT before the visitor can begin the experience in that location, the following prerequisite training must be completed with documented evidence. Reciprocity for OSHA blood borne pathogen and tuberculosis training from another institution completed within the previous 12 months may be accepted. Department-specific orientation should include BSOM specific information on use of PPE, and how to manage an exposure. Training prerequisite and evidence of compliance worksheet is in Attachment 2. Bloodborne Pathogen and Tuberculosis training; Effective Date: Revision/Review Date: Contact Person/Reference Source: Extension: ECU Physicians Group Practice, Director of Nursing Practice Office of Generalist Program Office of Academic and Faculty Development Revision/Review Person/ Source: Page 9 of 10

10 The Brody School of Medicine and ECU Physicians Group Practice Policy and Procedure Manual Topic: Student Training and Professional Visitor Policy - #A31 Section No. 1 Approval Date: Section Name: Administrative and Clinical Operations Dean Approval: Phyllis Horns, RN, DSN, FAAN Medical Director Approval: Todd Beste, MD BSOM HIPAA Privacy training if visitor will have any access to any patient information in any form oral, written, or electronic. Use of personal protective equipment; Hazardous materials precautions (MSDS); and Registration with Radiation Safety, if there will be any contact with radioactive material or radiation exposure. Department-specific training will be conducted and documented by the department s designated staff. Department-specific training might include but not be limited to a unit orientation, review of emergency procedures and evacuation plans, location and review of MSDS information, and documentation standards, etc. Animal Care and Use Training is site and institution specific and is required at ECU regardless of previous training elsewhere. 6. A BSOM visitor identification badge must be obtained and worn by the visitor at all times during the visiting/educational period. a. For the professional visitor who will be here less than 14 days, the Office of Academic and Faculty Development will issue a numbered visitor badge that must be worn by the visitor at all times during the visiting/educational period. b. For the professional visitor who will be here greater than 14 days, the visitor will obtain a photo identification badge in the same manner as employees. The Office of Academic and Faculty Development will complete the necessary request forms. c. When the educational experience has been completed, the badge must be retrieved from the individual and returned to the Office of Academic and Faculty Development with the individual s file. Other proper notification will be made according to the type of Identification Badge the visitor was issued. Attachments to the Policy Attachment 1 - Universal Affiliation Agreement Attachment 2 - Visitor Encounter Application Attachment 3 - Short Term Visitor Health Questionnaire Attachment 4 - Long Term Visitor Immunization History Attachment 5 Visitor Encounter Agreement and Release and Waiver From Liability Effective Date: Revision/Review Date: Contact Person/Reference Source: Extension: ECU Physicians Group Practice, Director of Nursing Practice Office of Generalist Program Office of Academic and Faculty Development Revision/Review Person/ Source: Page 10 of 10

11 The Brody School of Medicine and ECU Physicians Group Practice Policy and Procedure Manual Topic: Student Training and Professional Visitor Policy - #A31 Section No. 1 Approval Date: Section Name: Administrative and Clinical Operations Dean Approval: Phyllis Horns, RN, DSN, FAAN Medical Director Approval: Todd Beste, MD Attachment 6 Visiting Medical Student Application Attachment 7 BSOM Code of Conduct Attestation Form and BSOM Code of Conduct Effective Date: Revision/Review Date: Contact Person/Reference Source: Extension: ECU Physicians Group Practice, Director of Nursing Practice Office of Generalist Program Office of Academic and Faculty Development Revision/Review Person/ Source: Page 11 of 10

12 Affiliation Agreement Between AGENCY and ECU/BSOM AGREEMENT BETWEEN (NAME OF AGENCY) AND EAST CAROLINA UNIVERSITY BRODY SCHOOL OF MEDICINE This agreement made on (date), between the (NAME OF AGENCY) (hereinafter AGENCY ) and EAST CAROLINA UNIVERSITY, BRODY SCHOOL OF MEDICINE (hereinafter ECU/BSOM ). WITNESSETH WHEREAS, AGENCY, through its educational programs in the (Name of Agency s School) provide a degree program for (type of student); and WHEREAS, the AGENCY and ECU/BSOM desire to foster the education of (type of student) and desire to have such educational programs provided in North Carolina for the recruitment and training of qualified persons to become (type of student) in sufficient numbers to serve the region and the state; and WHEREAS, ECU/BSOM desires to offer its (specify department), staff, and expertise as a site for the clinical education of students enrolled in the (type of student) degree program for the purpose of increasing the practical knowledge of such students in their chosen fields, instilling in them an attitude of professionalism, and enhancing the student s knowledge and experience of healthcare, thus enhancing the training of such students about the realities of practice; and WHEREAS, in consideration of the terms stated herein, the AGENCY and ECU/BSOM agree to the following mutual responsibilities and terms: AGENCY agrees to do the following: 1. To sponsor, promote, and conduct within its curriculum educational programs that include a clinical experience component in the (type of student). 2. To require that its faculty and its students (as a condition for successful completion of the clinical training portion of the educational program) comply with the policies and procedures of ECU/BSOM during the clinical training portion of the educational program. 3. To submit a certification in the form provided herein as Appendix A signed by any student authorized to participate in a clinical experience at the ECU/BSOM in which the student certifies that he/she has been vaccinated or screened within the past 12 months for certain infections that might or could jeopardize patient and/or employee health at ECU/BSOM or indicates any such communicable disease or communicable health problem that he/she does have and agrees to immediately notify the ECU/BSOM (specify department) upon discovering that he/she has contracted any such communicable disease or communicable health problem. (Appendix B) Attachment 1 Page 1 of 10

13 Affiliation Agreement Between AGENCY and ECU/BSOM 4. To appoint a faculty member(s) who will coordinate with ECU/BSOM (specify department) the placement of students. The numbers and type(s) of students will be mutually agreed upon between the AGENCY and ECU/BSOM (specify department). 5. For its faculty, procure and maintain, and for its students, cause to procure and maintain (in the name of the student), liability insurance covering claims, causes of actions, actions, losses, liabilities, damages, and expenses arising out of, caused by, or otherwise resulting from acts of negligence committed by its faculty or students while in the performance of their duties or assignment pursuant to this Agreement. The limits of said liability insurance shall be at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) per aggregate. The insurance shall be provided by an insurance company licensed to do business in the State of North Carolina. AGENCY shall provide written documentation of insurance coverage to ECU/BSOM. 6. To adhere to the essential guidelines for regulatory and accreditation compliance specific to the particular academic disciplines covered pursuant to this Agreement. 7. To provide students with instruction on Infection Control, Blood-borne Pathogens, Tuberculosis, Substance Abuse Prevention, and OSHA Workplace Standards. ECU/BSOM agrees to do the following: 8. To offer its (specify department) as a site for a clinical learning experience for the AGENCY students in the (type of student) Program and to permit said students to rotate through the (specify department) for purposes of obtaining a clinical learning experience, and to foster among its agency s staff employees, both technical and professional, a teaching attitude of helpfulness to the University s students and/or faculty. 9. To provide appropriate equipment, space, and reference materials (as available) for students to facilitate the accomplishment of their clinical assignments; and when possible, to provide for use of support facilities. 10. To instruct students in the site-specific principles of HIPAA (Health Insurance Portability and Accountability Act), governing patient care and assure that students preserve the confidentiality of information concerning ECU/BSOM patients that they may encounter during their clinical experience. 11. To assign each student a preceptor to provide instruction in practical skills which meet the goals of the clinical experience component of the student s educational program in the areas mutually agreed upon by ECU/BSOM and the AGENCY. Instructors in practical skills shall be knowledgeable of and experienced in the performance of tasks incident to practical skills, and shall have applicable professional certifications or licenses. 12. To complete an evaluation of each student s clinical performance at times designated and on forms provided by the AGENCY. Attachment 1 Page 2 of 10

14 Affiliation Agreement Between AGENCY and ECU/BSOM 13. To provide on-premise emergency healthcare for students at Pitt County Memorial Hospital Emergency Department. Students are financially responsible for health care provided by ECU/BSOM. 14. Upon request, to provide copies of current ECU/BSOM policies and procedures to AGENCY during the term of this Agreement. General Provisions 15. INDEPENDENT CONTRACTOR: This Agreement does not create the relationship of AGENCY and/or its agents as an employee, agent, or legal representative of ECU/BSOM for any purpose whatsoever, it being the intent of the parties hereto to create the relationship with AGENCY and/or its agents as an independent contractor for whose actions or failure to act ECU/BSOM shall not be responsible. 16. EVALUATIONS: Student s performance will be evaluated by the faculty supervisor and/or preceptor who will consult with other providers who have worked with the student. AGENCY shall withdraw any student from the clinical experience to which this Agreement relates upon receiving written notification from ECU/BSOM to the effect that the student s performance in the clinical program is in violation of the policies, procedures, protocols, or other conditions that apply at ECU/BSOM or that there exist other reasonable causes why withdrawal is necessary. Prior to withdrawal from the clinical program, the student will be provided with notification concerning the intended withdrawal and the basis therefore, and shall be afforded an opportunity to respond to the notification. Such notification and response may be given verbally. The student response will not constitute an appeal. 17. LIABILITY: Each party on its behalf accepts responsibility for its tortuous acts to the extent allowed under the North Carolina Tort Claims Act, as set forth in Article 31 of the North Carolina General Statutes and/or other applicable legislation, and accepts responsibility for any and all claims, loss, liability, demands or damages due to its own negligence or the negligence of its agents or employees while in the performance of their duties or assignments pursuant to this Agreement to the extent permitted by law, except that each party does not agree to hold harmless the other party from any claims which may have resulted from error or omission by the other party and/or its agents or employees. 18. ENTIRETY: This Agreement contains the entire Agreement between the parties hereto and supersedes all prior and contemporaneous agreements, arrangements, negotiations and understanding between the parties hereto relating to the subject matter of this agreement. 19. ALTERATION: No supplement, modification, or amendment of the terms of this Agreement shall be binding or enforceable unless executed in writing by the parties to this Agreement. This Agreement is subject to annual review by the parties with a view toward modifying the Agreement, when necessary, on the basis of prior experience under the Agreement. 20. SEVERABILITY: If any provision of this Agreement is determined to be invalid or unenforceable, the provision shall be deemed to be severable from the remainder of the Agreement and shall not cause the invalidity or unenforceability of the remainder of this Agreement. Attachment 1 Page 3 of 10

15 Affiliation Agreement Between AGENCY and ECU/BSOM 21. WAIVER: The failure by the party at any time to require performance by the other party of any provision hereof shall not affect in any way the right to require such performance at a later time nor shall the waiver by either party of a breach of any provision hereof be taken or be held to be a waiver of such provision. Furthermore, no waiver of any term, provision or condition of this Agreement whether by conduct or otherwise in any one or more instances, shall be deemed to be, or shall constitute, a waiver of any other provision, whether or not similar, nor shall such waiver constitute a continuing waiver, and no waiver shall be binding unless executed in writing by the party making the waiver. 22 ASSIGNMENT: This Agreement shall not be assignable by either party without express, written consent of the other. 27. NOTICE: Any notice required or permitted to be given hereunder shall be in writing and shall be deemed to have been given when delivered personally or three (3) days after being mailed to the following addresses: AGENCY ECU/BSOM Gary R. Vanderpool Associate Vice Chancellor for Health Sciences Administration The Brody School of Medicine, Room AD-50 Greenville, North Carolina CONTRACT TERM: This Agreement is for a term of one year beginning ( ) and continuing through June 30,. Thereafter, this agreement is for a term of one year and may be renewed annually by written agreement of the parties. 25. TERMINATION: A. Any party shall have the right to terminate this Agreement, with or without cause, upon thirty (30) days notice in writing to the party, except that this Agreement will remain in full force and effect for any changes incurred prior to the date of termination. B. It is the understanding of the parties that this Agreement may be terminated pursuant to a breach of the Agreement upon thirty (30) days written notice to the breaching party by the non-breaching party, except as provided for in Section 20, above. 26. OBRA COMPLIANCE: The parties agree that, upon request, they will make their books, documents, and records available to the Secretary of Health and Human Services, the Comptroller Attachment 1 Page 4 of 10

16 Affiliation Agreement Between AGENCY and ECU/BSOM General, or their duly authorized representative to the extent required by Section 952 of the Omnibus Budget Reconciliation Act of 1980 and will obtain a similar agreement from any related sub-contractor whom they engage to perform on their behalf. 27. OTHER COMPLIANCE REQUIREMENTS: The parties agree that they will mutually comply with all other applicable regulatory requirements as detailed in Appendix C. 28. JURISDICTION: This Agreement has been entered into in the State of North Carolina and all questions with respect to the construction of this Agreement and the rights and liabilities of the parties shall be governed by the laws of the State of North Carolina. The headings and numbers of sections and paragraphs contained in this Agreement are for reference only and shall not affect, in any way, the meaning or interpretation of this Agreement. IN WITNESS WHEREOF, the parties have executed this contract on this day and year first above written. EAST CAROLINA UNIVERSITY DIVISION OF HEALTH SCIENCES BRODY SCHOOL OF MEDICINE EAST CAROLINA UNIVERSITY DEPARTMENT OF By: Phyllis N. Horns, RN, DSN, FAAN. Vice Chancellor for Health Sciences By: Chairman, Dept. of NAME OF AGENCY By: Name Title Date: Attachment 1 Page 5 of 10

17 Affiliation Agreement Between AGENCY and ECU/BSOM Appendix A** HEALTH SCIENCE STUDENT ROTATION AT ECU BRODY SCHOOL OF MEDICINE PERSONAL DATA (TYPE OR PRINT CLEARLY) Name Date of Birth (MM/DD/YY) First MI Last IMMUNIZATION DATA (MUST BE COMPLETED BY A SCHOOL HEALTH OFFICIAL) Tetanus-Pertussis-Diphtheria series... Dates / / & / / & / / Tetanus-Diphtheria booster < 10 years ago... Date of booster / / Varicella (Chickenpox or Shingles) Immunity by prior disease date OR two immunizations required Titer/Blood test Positive date of test / / OR Immunizations / / & / / TB test must be PPD test < 12 months before date of arrival Result of test circle Positive OR Negative...Date of test / / If last or any previous test was positive, state type and dates of treatment, and result and date of latest x-ray Hepatitis B one option must be met Vaccine series of three... Dates / / & / / & / / OR Hepatitis B Antibody Test: Positive OR Negative (circle one)...date of test / / SECTION A Complete Section A OR Section B, not both Measles/Mumps/Rubella (MMR) TWO doses after 12 months of age and after 4/22/71...Dates / / & / / SECTION B Measles (Rubeola) one option must be met: Two immunizations after 12 months of age and after 3/21/73...Dates / / & / / OR Blood titer documenting immunity... Date of test: / / Mumps Immunization after 12 months of age and after 12/28/67...Date of test / / Rubella (German Measles) one option must be met: Two immunizations after 12 months of age and after 6/9/69...Dates / / & / / OR Blood titer documenting immunity...date of test / / BLOODBORNE INFECTIONS OF SPECIAL CONCERN IN HEALTHCARE PERSONNEL Have you been diagnosed with HIV (Human Immunodeficiency Virus)? Yes No Have you been diagnosed with Chronic Hepatitis B (lasting longer than 6 months)? Yes No Attachment 1 Page 6 of 10

18 Affiliation Agreement Between AGENCY and ECU/BSOM Appendix A Continued TRAINING 1. I have completed a training program in universal precautions ensuring the appropriate handling of blood, tissues, and body fluids. Date course completed (month/year) /, OR No training. 29. I have completed a training program regarding confidentiality of medical records and information. Date completed (month/year) /, OR No training. I hereby certify that I meet all requirements of the Brody School of Medicine. Student Signature Date Program Representative Signature Date Please send a completed Appendix A for each student to the Brody School of Medicine department representative who is coordinating this program activity. **NOTE Appendix A is available as a separate electronic document to allow for duplication of the form to use for multiple students. Attachment 1 Page 7 of 10

19 Affiliation Agreement Between AGENCY and ECU/BSOM APPENDIX B AGENCY CERTIFICATION OF PHYSICAL STATUS OF STUDENT AGENCY does hereby certify that the students named on the attached list are enrolled in the (Name of Agency s School/Program) and, to the best of its knowledge, do not presently have a communicable disease or communicable health problem that might or could jeopardize patient or employee health at ECU/BSOM. The (Name of Agency s School) at AGENCY hereby agrees to immediately notify ECU/BSOM if it becomes aware that any student on this list contracts or becomes aware that he or she has a communicable disease or communicable health problem that might or could jeopardize patient or employee health care at ECU/BSOM. This the day of 200. (Print or type name) Signature Title Attachment 1 Page 8 of 10

20 Affiliation Agreement Between AGENCY and ECU/BSOM APPENDIX C MUTUAL AGREEMENTS BETWEEN AGENCY AND EAST CAROLINA UNIVERSITY/BRODY SCHOOL OF MEDICINE PROVIDING CLINICAL EDUCATION FOR (TYPE OF STUDENT) STUDENTS AGENCY and ECU/BSOM hereby agree as follows: 1. East Carolina University supports the protections available to members of its community under all applicable Federal laws, including but not limited to Title VI and VII of the Civil Rights Act of 1964, Sections 799A and 845 of the Public Health Service Act, the Equal Pay and Age Discrimination Acts, the Rehabilitation Act of 1973, the Vietnam Era Veteran s Readjustment Assistance Act of 1974, and Executive Order Compliance with provisions of these laws pertaining to University policy in regard to non-discrimination herein made a part of this Agreement. 2. There shall be no discrimination on the basis of, among others, disability in either the selection of students for clinical practice or as to any aspect of the clinical practice experience; provided, however, that the disability must not be such as would, even with reasonable accommodation, in ad of itself preclude the student s effective participation in the activities which make up the terms of this Agreement. 3. The Family Educational Rights and Privacy Act (PL ) relative to release of information on students are incorporated herein; the parties agree to comply fully with all aspects of the aforementioned Act. 4. To cooperate in long and short term planning necessary to insure high quality clinical/field education experience at the Affiliating Agency for students 5. That the number of students eligible to participate and the schedule of participation in AGENCY S clinical/field education program will be mutually determined by the parties above represented except that no more than students will be assigned to one faculty member per specific clinical experience. 6. To inform that other party of changes in curriculum, availability of learning opportunities, or staffing affecting clinical preparation of students prior to the beginning of a clinical/field education term or as early as feasible. 7. That this association between the ECU/BSOM and AGENCY involves no exchange of money of financial obligation on the part of either party. AGENCY agrees: 1. That AGENCY shall retain direct responsibility for and control of its students education n (type of degree) through one or more members of its own faculty in its unit of (type of degree). Attachment 1 Page 9 of 10

21 Affiliation Agreement Between AGENCY and ECU/BSOM APPENDIX C Continued 2. That the AGENCY shall be responsible both for classroom teaching and for the students clinical educational program. 3. That AGENCY (Name of Agency s School) students in shall be governed by the same policies as govern other students with respect acts of misconduct (cheating, plagiarism, etc.) during the clinical educational experience as provided in applicable East Carolina University policies. 4. To provide professional instructional personnel for students assigned to the facility for clinical experience and it will be the responsibility of AGENCY instructors to become familiar with the policies, standards, whatever school procedures and physical set-up of the facility and to orient the students. 30. To provide and maintain the records and reports of students necessary for conducting the student s clinical education program. ECU/BSOM agrees: 1. That ECU/BSOM shall retain direct responsibility and control of its health delivery services. 2. To provide and maintain (type of student) supervision of patient care as prescribed by the policies and standards of the North Carolina Board of Nursing and the North Carolina Board of Medicine, and all other regulatory and accreditation bodies. 31. To make available for student learning experience direct patient care, in all units as needed, as well as learning opportunities in appropriate rounds, staff meetings, in-service education programs and similar activities. IN WITNESS WHEREOF, the parties have executed this Appendix C to this contract on this day and year first above written. EAST CAROLINA UNIVERSITY BRODY SCHOOL OF MEDICINE By: Phyllis N. Horns, RN, DSN, FAAN. Interim Vice Chancellor for Health Sciences and Interim Dean for Brody School of Medicine NAME OF AGENCY By: Name Title Agency Name Attachment 1 Page 10 of 10

22 BRODY SCHOOL OF MEDICINE VISITOR ENCOUNTER APPLICATION STUDENTS FROM FORMAL ENRICHMENT PROGRAMS, INDIVIDUAL STUDENT AND/OR PROFESSIONAL VISITOR Instructions: This application must be completed by the visitor and the sponsoring department to include: (1) The application, (2) either Short Term Visitor Health History or Long Term Visitor Immunization (appropriate to the time span of the educational experience), (3) BSOM Assumption of Risk and Release Form, with parent or legal representative s signature if visitor under the age of 18, (4) Evidence (Certificate of Insurance) of adequate professional liability coverage for professional healthcare visitor who is licensed and/or credentialed. The completed package is to be forwarded to the Office of Generalist Program (Students From Formal Enrichment Programs or Individual Student), Office of Academic and Faculty Development (Professional Visitors) or Office of Student Affairs (Medical Students). The Office will review the application packet for completeness and render the final approval for the educational experience. Before the educational experience can begin, the minimum prerequisites attached on the subsequent pages must be met with evidence of compliance. Visitor Name Age Address Phone School Grade or Year If non-student, please specify status (visiting professional, community member, etc.) BSOM Department Contact Phone Responsible Faculty/Preceptor Type of experience requested Dates of Requested Experience: Begin: End: Request reviewed/approved by Department Chair, Associate Dean or designate?...yes No Signature of Department Chair, Associate Dean or designate Visitor application with supporting documents reviewed/approved by either the Office of Generalist Programs or Office of Academic and Faculty Development?... Yes...No Signature of Office Attachment 2 Page 1 of 3