Healthcare Education Agreement

HEALTHCARE EDUCATION AGREEMENT

This Healthcare Education Agreement (the Agreement) is entered into on by and between Facility Name: and Student Name: .

1. Facility and Program Information

Program Start Date:    Program End Date:    Scheduled Hours/Week:

2. Student Information and Health Details

Phone:    Email:    DOB:

Gender:

Relationship:    Phone:

Immunizations on file and records provided to Facility.    TB Test Date:

Influenza vaccine current for the season.

3. Insurance and Liability

Policy Number:    Group Number:    Subscriber Name:

Student acknowledges that Facility does not provide personal health or professional liability insurance for students unless explicitly stated in a separate written agreement. Student shall obtain and maintain, at Student's expense, professional liability insurance with limits sufficient to meet Facility's requirements where applicable.

4. Background Checks, Drug Screening and Health Requirements

Student consents to background checks and criminal history screening as required by Facility and agrees that any adverse result may be grounds for denial of placement or termination from the program.

Student consents to drug and alcohol screening as required by Facility and understands that a positive result may preclude participation.

5. Confidentiality, HIPAA and Privacy

Student will comply with all federal and state privacy laws, including but not limited to statutes and regulations governing protected health information. Student may have access to patient information only to the extent necessary for educational activities and only under supervision. Student shall not access, disclose, photocopy or transmit protected health information except as expressly authorized for clinical instruction. Unauthorized access or disclosure is grounds for immediate termination and may result in civil or criminal liability.

Student confirms completion of HIPAA privacy and security training prior to patient contact: Training Completed.

Authorization to use or disclose Student educational records, clinical evaluations, or limited protected health information for purposes of evaluation and program accreditation expires on:

6. Performance, Evaluation and Termination

Student shall comply with Facility policies, dress codes, safety rules, and infection control procedures. Facility will provide supervision and periodic evaluation. Facility reserves the right to terminate Student's participation for safety concerns, failure to meet performance standards, breach of confidentiality, or noncompliance with requirements. Termination may be immediate where patient safety or legal obligations are implicated.

Notice of intent to terminate will be provided in writing where practicable. If notice is required, the notice period will be days unless immediate removal is warranted.

7. Indemnification and Limitation of Liability

Student agrees to indemnify and hold harmless Facility, its officers, employees and agents from claims, liabilities, costs or damages arising from Student's negligent acts or omissions while participating in the Program, except to the extent caused by Facility's gross negligence or willful misconduct. Facility shall not be liable for Student's personal property loss or incidental injuries except as provided by law.

8. Intellectual Property and Records

Any educational materials, evaluations, assessments, and clinical records created by Facility remain the property of Facility. Student may not reproduce or distribute such materials without prior written authorization. Facility may use anonymous aggregated evaluation data for educational quality improvement and accreditation.

9. Certification and Acknowledgment

By signing below, Student certifies that the information provided in this Agreement is true and complete to the best of Student's knowledge; Student agrees to comply with Facility rules and applicable laws; Student acknowledges receipt of the Facility's privacy policies and agrees to the confidentiality provisions contained herein.

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