ࡱ> { Rbjbjrr ?jjJ[l l eeeeeyyy8ly_9  .777&j9999999;=9e && 9ee779V%V%V% ^e7e79V% 9V%V%"2|37pij 2F8/90_92w>B"w>$33w>e3  V% 99# _9 w> l +: TENNESSEE STATE UNIVERSITY CLINICAL AFFILIATION AGREEMENT This Clinical Affiliation Agreement (the Agreement) is made by and between TENNESSEE STATE UNIVERSITY, hereinafter referred to as the Institution, and __________________, hereinafter referred to as the Affiliate. WITNESSETH In consideration of the mutual promises contained herein, the parties hereby agree and enter into this Agreement according to the provisions set forth below: Purpose. The purpose of this Agreement shall be to provide clinical experience to students enrolled in the _______________________________ program(s) of Institution. The parties agree that monetary compensation shall neither be expected nor received by either party. Location. The clinical experience shall be provided at Affiliates facility or, if multiple locations, facilities, hereinafter referred to as the Facility. The Facilitys principal address is listed in the Notices provision of this Agreement. Responsibilities of Affiliate. Designate a trained staff member as Affiliates clinical education coordinator to: Direct and coordinate the student clinical education experience at the Facility; Provide a planned and supervised clinical education program, which utilizes observational opportunities and practical experiences, for students; Provide orientation for students beginning clinical experience at the Facility; Provide necessary feedback to students to facilitate student learning; and Notify Institution of any situation which may threaten a students successful completion of the clinical program. Retain complete responsibility for patient care while providing adequate supervision of students (and faculty, if applicable) at all times. Maintain a current list of all personnel who, in any way, supervise students. Maintain a sufficient level of staff employees to carry out regular duties. Students will not be expected nor allowed to perform services in lieu of staff employees. Retain the right to require students (and faculty, if applicable) participating in the clinical experience to have or obtain immunizations or testing reasonably required by Affiliate. Provide emergency medical treatment to students (and faculty, if applicable) for illness or injuries suffered during the clinical experience. If the Facility does not have the necessary resources to provide such treatment, Affiliate shall direct the individual to the nearest emergency facility. Such treatment shall be at the expense of the individual treated. Allow students to participate in non-treatment learning experiences such as ward rounds, clinics, conferences, special lectures, observations, and similar activities as available. Maintain all applicable accreditation requirements, and certify compliance to Institution or another entity, as requested by Institution, as well as permit authorities responsible for accreditation of Institutions curriculum to inspect clinical facilities, as necessary. Confirm that students will be supervised by the appropriate licensed professional(s) who shall have a minimum of one (1) year of full-time experience in a practice setting. Confirm that students shall be treated as trainees who shall have no expectation of receiving compensation or future employment from Affiliate. Evaluate each students clinical performance and submit to Institution a performance appraisal for each student, including the scoring of the evaluation instrument, at both the middle and end of the clinical experience, or as otherwise agreed upon by the parties. Provide an opportunity for students to conduct a performance self-appraisal with the same evaluation instrument as mentioned above, at both the middle and end of the clinical experience, or as otherwise agreed upon by the parties. Work with Institution to ensure that the clinical experience is meeting, and continues to meet, the academic needs of students and the requirements of the academic program. Notify Institution in writing of any changes within the Facility which would significantly alter the specified clinical education experience for students. Provide Graduate Speech and Language Therapy students, where applicable, with a minimum of 25% supervision while conducting speech and language therapy and 50% supervision while administering speech and language diagnostic evaluation. Responsibilities of Institution. Place a mutually agreed upon number of students at the Facility each academic term. Provide educational orientation for students beginning clinical experience at the Facility. Work with Affiliate to schedule training activities for students (and faculty, if applicable). Provide supervision to students during clinical experience at the Facility, as necessary. Maintain responsibility for the educational component of the clinical experience and evaluate the performance of students. Provide health records of students (and faculty, if applicable) to Affiliate upon request, to the extent permitted by applicable law. Establish a procedure for notifying Affiliate if a student (or faculty, if applicable) is unable to report for clinical training. Notify students (and faculty, if applicable) of Affiliates health insurance requirements for individuals participating in the clinical experience, and require individuals to provide written evidence of such insurance coverage. Inform students that they shall not submit for publication any material relating to the clinical experience without prior written approval from Institution and Affiliate. Mutual Responsibilities. Compliance with Policies. Students, faculty, and/or staff of Institution and Affiliate are expected to conduct themselves in accordance with the applicable Code of Ethics, as set forth by the national guidelines for the particular field of work/study. Students (and faculty, if applicable) will be subject to the applicable policies of Institution and Affiliate while participating in the clinical experience. Affiliate may immediately remove from the Facility any student who poses an immediate threat or danger. Institution may dismiss students from participation in Institutions program only after the appropriate disciplinary or academic policies and procedures of Institution have been followed. Background Checks and Drug Screenings. If criminal background checks and/or drug screenings of students are required by Affiliate, Institution shall notify students of this requirement prior to enrollment in the clinical program or as soon as the requirement is known. Institution shall inform students that background checks and/or screenings must be completed prior to the students initial clinical placement. It shall be each students responsibility to make timely arrangements for and pay all costs associated with background checks and/or screenings. If criminal background checks and/or drug screenings are required for Institution faculty, Institution shall arrange for the background checks/screenings and provide the results to Affiliate. Affiliate shall be responsible for setting the eligibility standards for clinical participation at the Facility. If there is any question as to whether the standards have been met, Affiliate shall evaluate the results of background checks and/or drug screenings to determine if a student or faculty member shall be allowed to participate in the clinical experience. If Affiliate determines that a student or faculty member shall not participate in the clinical experience, Affiliate shall promptly notify Institution. If an Institution student or faculty member is also an employee of Affiliate, Affiliate will allow the student or faculty member to participate in the clinical program without undergoing an additional background check. If an Institution student or faculty member is an employee at another hospital or healthcare facility, Affiliate may allow the student or faculty member to participate in the clinical program without undergoing an additional background check. Recognizing that students may participate in multiple clinical placements at multiple facilities, Affiliate may agree to accept the results of a background check done prior to a students placement at the Facility if the student maintains continuous enrollment in Institutions program and if the background check agency maintains the results of the background check. Institution shall inform students or faculty members, who are excluded from clinical placement on the basis of the results of a criminal background check and/or drug screening, of any review or appeal process available pursuant to Institution policies, the Fair Credit Reporting Act, or any other applicable law. Confidential Information. The confidentiality of patient and student records shall be maintained at all times, in accordance with state and federal laws and as set forth below: HIPAA Compliance. To the extent required by federal law, the parties agree to comply with the Health Insurance Portability and Accountability Act of 1996, as codified at 42 U.S.C. 1320(d) (HIPAA) and any current and future regulations promulgated thereunder, including without limitation, the federal privacy regulations and the federal security standards, as contained in 45 C.F.R. 164. The parties acknowledge, and Institution shall inform its students, that students are required to maintain protected health information, as defined at 45 C.F.R. 160.103, of Affiliates patients and all other information which relates to or identifies a particular patient, including but not limited to the name, address, medical treatment or condition, financial status, or any other personal information which is deemed to be confidential under applicable state and federal laws. Each party agrees to make its internal practices, books, and/or records relating to the use and disclosure of protected health information available to the appropriate authorities to the extent required by law. The parties agree that only for purposes of HIPAA, students shall be considered members of Affiliates workforce, as defined at 45 C.F.R. 160.103, when receiving training at the Facility, and as such, neither party shall be considered a business associate of the other. Notwithstanding the foregoing, students shall not be considered employees of Affiliate. FERPA Compliance. The parties acknowledge that students education records are protected by the Family Educational Rights and Privacy Act (FERPA), and Affiliate will be considered a "School Official" (as that term is used in FERPA and its implementing regulations) and will comply with all FERPA provisions if accessing such records. Student education records will only be used for the purposes of carrying out this Agreement. Student permission must be obtained before releasing specific data to anyone other than Institution and/or Affiliate employees who have a legitimate educational purpose. Privacy and Data Protection. Affiliate represents and warrants that its collection, access, use, storage, disposal, and disclosure of personal or protected information complies with all applicable privacy and data protection laws, as amended, and any current and future regulations promulgated thereunder, including without limitation, the Gramm-Leach-Bliley Act (GLBA) and the Federal Trade Commission (FTC) Red Flag Rule on identity theft. Standard Terms and Conditions. Term. The term of this Agreement shall be from ____________ to ________________. This Agreement may be renewed through a written amendment signed by the parties hereto. Under no circumstances shall the total term of this Agreement exceed five (5) years, including all extensions and renewals. Termination. This Agreement may be terminated by either party upon at least thirty (30) days written notice to the other party. Termination of this Agreement shall have no effect on students receiving clinical experience at the Facility at the time of termination, and students shall be given the opportunity to complete their clinical experience. Force Majeure. The parties obligations under this Agreement shall be voided in the event of an occurrence beyond the parties control that could not be avoided by the exercise of due care, including, but not limited to, acts of God, riots, wars, epidemics or pandemics, declaration of a federal, state, or local state of emergency, or any other similar occurrence or cause. Remedies. The delay or failure of performance by either party shall not constitute default under the terms of this Agreement, nor shall it give rise to any claims against either party for damages. The sole remedy for breach of this Agreement shall be immediate termination. Institution, as a State of Tennessee entity, shall not, under any circumstances, indemnify, defend, or hold harmless any party, including Affiliate, or be liable for attorneys fees, punitive damages, or the costs of litigation. Each party shall be solely liable for payment of its portion of all claims, liability, costs, expenses, demands, settlements, or judgments resulting from its own negligence or the negligence of those for whom it is legally responsible relating to or arising under this Agreement. Any and all monetary claims against the State of Tennessee, including Institution, its officers, agents, and employees, in performing any responsibility specifically required under the terms of this Agreement shall submitted to the Board of Claims or the Claims Commission of the State of Tennessee and shall be limited to those provided for in T.C.A. 9-8-307. Insurance. Affiliate agrees to carry and maintain adequate liability insurance, as well as any other forms of insurance required by law. Institution is self-insured under the Tennessee Claims Commission Act, T.C.A. 9-8-301 et seq., and does not carry or maintain general liability insurance or medical, professional, or hospital liability insurance. This self-insurance is effective for acts or omissions of Institution and its employees. Institution maintains an occurrence-based liability policy for healthcare provider students, with limits of at least $1,000,000/$3,000,000 ($1,000,000/$6,000,000 for Nursing and Dental Hygiene students). If Affiliate requires additional liability coverage for students participating in the clinical experience, students shall be responsible for procuring any additional coverage at the limits required by Affiliate. Non-Assignment. Neither party shall assign this Agreement or enter into subcontracts for any of the work herein without obtaining the prior written approval of the other party. Relationship of Parties. The parties hereto shall not act as employees, agents, partners, joint venturers, or associates of one another in the performance of this Agreement. The parties acknowledge that they are independent contracting entities and that nothing in this Agreement shall be construed to create an employer-employee relationship or to allow either to exercise control or direction over the manner or method by which the other transacts its business affairs or provides its usual services. Confidentiality. Institution does not have the authority to consent to provisions which require confidentiality or nondisclosure in violation of the Tennessee Open Records Act. Therefore, each party shall treat the other partys confidential information as confidential to the extent permitted by applicable state and federal laws. Specifically, each party receiving confidential information agrees not to disclose such confidential information, except to its directors, officers, employees, and agents, in accordance with applicable law, and shall use the same care to prevent disclosure of such confidential information as each party uses with respect to its own confidential information; provided that, in any case, each party shall not use less than the care a reasonable person would use under similar circumstances. Non-Discrimination. The parties agree to comply with all applicable state and federal laws pertaining to discrimination. Affiliate agrees, warrants, and assures that no person shall be excluded from participation in, be denied benefits of, or otherwise be subjected to discrimination in the performance of this Agreement or in the employment practices of Affiliate on the grounds of handicap or disability, age, race, color, religion, sex, national origin, or any other classification protected by law. Notices. Any notice, request, approval, or consent required or permitted to be given under this Agreement shall be in writing and deemed to have been sufficiently given if delivered in person, sent by nationally recognized overnight carrier service with confirmation of receipt, or sent by certified or electronic mail, return receipt requested, to the party to whom it is directed at its address shown below: If to Institution: Tennessee ӰԺַ Attn: [Contract Agent Name, Department] 3500 John A Merritt Boulevard Nashville, TN 37209 Email: __________________ With a Copy to: Tennessee ӰԺַ Attn: Office of the General Counsel 3500 John A. Merritt Boulevard Nashville, TN 37209 Email: legalnotice@tnstate.edu If to Affiliate: [Insert Affiliate Name] Attn: __________________ [Address Line 1] [Address Line 2] Email: __________________ Compliance with Laws. The parties shall comply with all applicable federal, state, and local laws and regulations in the performance of this Agreement. Entire Agreement. This Agreement shall constitute the entire agreement between the parties relating to the subject matter contained herein. This Agreement supersedes any and all prior understandings, representations, negotiations, and agreements between the parties, whether written or oral. Modification. This Agreement may be modified only by a written amendment signed by the parties hereto. Headings. Section headings are for reference purposes only and shall not be construed as part of this Agreement. Counterparts. This Agreement may be executed in separate counterparts, each of which is deemed to be an original and all of which taken together constitute one and the same Agreement. Severability. If any terms or conditions of this Agreement are held to be invalid or unenforceable as a matter of law, the other terms and conditions hereof shall not be affected and shall remain in full force and effect. To this end, the terms and conditions of this Agreement are declared severable. Assent. This Agreement shall not be binding upon the parties until it is signed by each partys authorized official(s). For Institution, this shall be Institutions President or the Presidents authorized designee. [SIGNATURE PAGE FOLLOWS] IN WITNESS WHEREOF, the parties, through their duly authorized representatives, have set forth their signatures below: TENNESSEE STATE UNIVERSITY AFFILIATE Signature: Signature: _____ Name: Name: Title: President/Presidents Designee Title: Date: Date:     PAGE  PAGE  PAGE 6 OGC Rev. 07.01.2025 OGC Rev. 07.01.2025 $:;@IU_qy̽}n_OO?hm'hM5CJOJQJ^Jhm'hi9CJOJQJ\^Jhm'hu,CJOJQJ^Jhm'hW?CJOJQJ^Jhm'hi95CJOJQJ^Jhm'h9:CJOJQJ\^Jhm'hCJOJQJ\^Jhm'hu,CJOJQJ\^Jhm'hi9CJOJQJ^J#hm'hi95CJOJQJ^JaJ#hm'h*5CJOJQJ^JaJhZa5CJOJQJ^JaJ:;  " # $ & F^`a$gd8C` $8^8a$gd8C`$ & F^`a$gdt%> $^a$gdAs$ & F^`a$gd$a$gdkV $`a$gd9:$a$ $da$gdZa     ! 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