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AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE
THIS AFFILIATION AGREEMENT FOR
FIELD INTERNSHIP EXPERIENCE is made between
College of Emergency Services, Inc "School and Port
Angeles Fire Department "Contractor" effective as of
August 1, 2012
WHEREAS, School is a program which offers a program of
instruction leading to certification or licensure of its students as
Emergency Medical Technician, Emergency Medical Technician-
Paramedic and other, similar health care and pre hospital
providers "Students
WHEREAS, As a part of the licensing and/or certification
requirements Students must complete a course of study including
a field internship experience "Field Internship Experience by
and through assignment to various mobile intensive care units
operated by Contractor,
WHEREAS, Contractor is a provider of emergency medical
service, including both advanced life support and basic life
support pre- hospital care and transport, and Contractor has
agreed to assist School by providing a limited Field Internship
Experience for Students, upon certain terms and conditions, so
long as its participation in the program does not jeopardize
patient care or compromise Contractor's standards of service to
its patients
NOW THEREFORE, in consideration of the foregoing and for
other good and valuable consideration, the receipt and sufficiency
of which are hereby acknowledged, the parties hereto agree as
follows
1. TERM.
1.1. Commencement Date. This agreement shall become
effective when signed by all of the parties "Effective
Date and completion of the written approval and
certification contemplated in paragraph 2 2, 2 3 and
2.4 This agreement shall be for a term of twenty-
four(24) months from the Effective Date. Any
renewal shall be set forth in a writing signed by the
parties
1.2. Termination. This agreement may be terminated by
either party, with or without cause, upon thirty (30)
days written notice to the other party as provided
herein.
2. RIGHTS AND OBLIGATIONS OF SCHOOL
2.1. School's Accreditation School shall maintain a
qualified educational program for Students designed to
provide a smooth transition into licensure /certification
of Students as Emergency Medical Technicians,
2007 NCTI Affiliation Agreement
Confidential and Proprietary
City of Port Angeles
Record #000511
Emergency Medical Technician- Paramedics or other
similar pre hospital health care providers. School's
program shall include programming, administration,
matriculation, promotion and graduation and shall be
approved or accredited by relevant licensing/certifying
agencies in the state(s) and county(ies) in which
School resides and in which the program contemplated
herein is to operate.
2.2. Approval by Licensing /Certifying Agency(ies)
School shall secure from all relevant
licensing/certifying agencies written approval for the
Field Internship Experience program contemplated
herein and shall maintain such approval throughout
the course of the program. School shall provide
Contractor with a copy of the written approval and
applicable guidelines or protocols applicable to the
program before assigning a Student to the Field
Internship Experience program.
2.3. Student Licensure /Certification School shall
ensure that each Student enrolled in the clinical
program is compliant with any licensure certification
required for participation in this program, which may
include, but is not limited to state EMT and CPR
credentials or any provisional licensure /certification
School shall provide Contractor with a copy of the
requisite licensure and or certification for any Student
enrolling in the Field Internship Experience before the
Student is allowed to participate in the program
unless, the licensing/certifying agencies advise School
and Contractor, in writing, that licensure /certification
is not required and the Field Internship Experience
program is approved under all applicable, or
potentially applicable, laws and regulations.
2.4. Approval by Doctor or Agency Having Medical
Control. If applicable, School will secure from the
doctor or agency having medical control in the state(s)
or county(ies) in which program will operate, written
approval for the Field Internship Experience Such
written approval shall, at a minimum, define the scope
of practice and required supervision of any Student
participating in the course of clinical education.
School will provide Contractor with a copy of the
approval contemplated in this paragraph before
assigning any Student to the clinical program
2.5. Records School will keep and maintain accurate
records for all Students participating in the Field
Internship Experience. The records will include the
Students transcript, licensure or certification,
temporary license or certification (if applicable), pre
assessment health record, and record of history
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AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE
vaccination immunization as set forth in paragraph
2.8 hereof. School will maintain the records for a
period of at least four (4) years (or any greater period
as may be required by applicable) from the date
Student completes, or ceases to participate in, the
Field Internship Experience contemplated herein.
2.6. List of Participants, Qualifications, Objectives and
Representations. School will notify Contractor at
least thirty (30) days prior to the inception of a course
of Field Internship Experience of the names,
qualifications and performance objectives for each
Student scheduled to begin their Field Internship
Experience. Inclusion by School of a Student's name
on this list is School's representation that the Student
possesses the necessary skills, licensure /certification
and immunizations to engage in the Field Internship
Experience The School shall comply with any
requirements or procedures that Contractor requires
regarding documentation to verify the Student's
qualifications for the Field Internship Experience.
2.7. Contractor Rules and Regulations. School will use
all reasonable efforts to cause Students to comply with
Contractor's policies, procedures, work rules and
regulations, including preservation of the
confidentiality of patient care and patient care records
School will, prior to allowing a Student to participate
in the Field Internship Experience, review patient
confidentiality as well as the Contractor's policies,
procedures, work rules and regulations with Student
and secure Student's agreement to abide by all such
rules and regulations.
2.8. Pre assignment Health Assessment School will
cause Student to complete a pre assignment health
assessment, at Student's or School's expense, which
includes, but is not limited to history of
communicable diseases and immunizations, proof of
tetanus vaccination or immunization, proof of
Hepatitis B vaccination or executed declination and
waivers of the Hepatitis B vaccination by the Student,
proof of MMR vaccination, respiratory certification by
a physician and PPD test. School will provide proof
of satisfactory completion/vaccination to Contractor
upon request Inclusion of a Student's name on the list
referenced in paragraph 2 6 is School's representation
that Student has completed the pre assignment
assessment and is physically able to perform the tasks
associated with the program.
2.9. OSHA Compliance. Prior to allowing Student to
enroll in the course of Field Internship Experience,
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School will educate and train Student in compliance
with all relevant and required OSHA regulations
including, but not limited to, Blood -borne Pathogens
Standard and TB Standard
2.10. Personal Protective Equipment School shall
provide Student with all necessary personal protective
equipment, including fitting, as is, or may be, required
by OSHA or other regulatory agency as required in
locale of Contractor prior to assignment to the Field
Internship Experience Such equipment may include.
safety glasses, face shields and particulate respirators
School recognizes and will inform Student that this
equipment must be in the possession of the Student as
a condition of their participation in the program.
Failure to possess and use the required OSHA
equipment will result in Student's dismissal from the
program
2.11. Assistance in Obtaining Signatures and
Compliance School recognizes that its Students have
certain obligations and will be required to execute
certain documentation in order to be eligible to
participate in the program School shall assist
Contractor m obtaining any necessary signatures and
ensuring Student compliance with Contractor rules
and this agreement including, but not limited to, those
contained in part 3 of this agreement.
2.12. Evaluation of Performance School, in conjunction
with Contractor personnel, is responsible for and shall
make arrangements for evaluating Student's
performance during the clinical program.
2.13. Minimum Age of Participants School and
Contractor will only allow Students that are at least
eighteen (18) years of age to participate in this
program. Inclusion of a Student's name on the list
referenced in paragraph 2.6 is School's representation
that Student is at least eighteen (18) years of age
3. STUDENT OBLIGATIONS AND REQUIREMENTS
3.1. Release. Student will, prior to participating in the
clinical experience, read, understand and sign a ride
along waiver releasing Contractor from any and all
liability and/or responsibility arising out of Student's
participation in the Clinical Experience. This release
of claims must be executed, and on file with the
School, prior to Student participation in the program
The release is a condition precedent to Student's
participation in the clinical experience and no Student
will be permitted on a Contractor vehicle without
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having signed the release. The release is attached
hereto and made a part hereof as Exhibit A
3.2. Pre assignment Health Assessment Student shall
complete a pre assignment health assessment as set
forth in paragraph 2.8 hereof.
3.3. Contractor Rules and Patient Confidentiality
Student shall comply with Contractor's procedures,
policies, rules and regulations, including maintenance
of patient and records confidentiality. Students, while
participating in the clinical program, on Contractor
property, must meet all standards of appearance and
conduct required by Contractor of its own employees
Student shall comply with all applicable OSHA rules
or regulations. Student shall have in their possession
at all times when on board a Contractor vehicle
personal protective equipment and use such equipment
when, as and where designated by Contractor
personnel Any information generated as a result of
the activities set forth in this agreement, including
information regarding patients or business activities of
Contractor, as well as any information regarding the
students and their performance or the Training
Program itself, shall remain confidential. Students
will be required to sign an acknowledgement of their
understanding of the mandates for confidentiality as
imposed by the U.S. Health Insurance Portability and
Accountability Act of 1996 (HIPAA); the U S.
Privacy Act of 1974 and any applicable state laws.
3.4. Student Intern Agreement. Student will read and
execute the student intern agreement Execution of
the student intern agreement is a condition precedent
to participation in the Field Internship Experience
program The student intern agreement is attached
hereto and made a part hereof as Exhibit A
4. CONTRACTOR RIGHTS AND OBLIGATIONS.
4.1. Contractor Rules. Contractor requires Students,
while participating in the clinical program, on
Contractor property, to meet all standards of
appearance and conduct required by Contractor of its
own employees. Contractor reserves the right to
refuse to allow any Student to participate in the
clinical program for failure to comply with Contractor
standards.
4.2. Student's Skill Level Contractor reserves the right
to discontinue Student's participation in the program
should Contractor, in its sole discretion, determine that
Student's skill level is substandard Contractor will
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AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE
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immediately advise School of any such concerns or
situations.
4.3. Orientation Program. Contractor may require
Student to attend an orientation program designed to
orient Student to Contractor's rules regulations and
policies prior to beginning their Field Internship
Experience. The details and procedures for the
orientation program shall be in the Contractor's sole
discretion
4.4. Contractor's Control of Patient Care Contractor
reserves the right to determine where, when and if a
Student may participate in the provision of care to its
patients. Contractor will endeavor to utilize Student,
and allow them to utilize as many of their skills in as
many situations as possible. However, patient care is
paramount and Student shall follow Contractor's
instructions with respect to the provision of patient
care.
4.5. Right to Control Participation Company reserves
the right to refuse to allow any Student to participate
in the provision of care at the scene of an emergency
where, in company's sole discretion, permitting
Student to participate would endanger the Student, a
patient or an employee of Company or otherwise be
inappropnate.
4.6. Student Evaluations. Contractor will cooperate with
School in performing evaluations of Student's Field
Internship Experience
4.7. Provision of Field Internship Experience
Contractor will provide a Field Internship Experience
for the School's Students in compliance with the
guidelines, protocols, scope of practice provided by
the licensing/certifying agency and in accord with the
instructions of the doctor or agency having medical
control, if applicable The number of Students that
Contractor accepts into the Field Internship
Experience shall be determined by mutual agreement
between School and Contractor.
5. INDEMNIFICATION
5.1. Indemnity for Third Party Claims. School will
save, defend, indemnify and hold harmless Contractor,
its officers, employees, agents, affiliates and
representatives of and from any and all claims, suits,
costs and actions arising out of the provision of the
Field Internship Experience This indemnity shall
survive and remain enforceable after the expiration or
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5.2. Indemnity for Student Claims School will save,
defend, indemnify and hold harmless Contractor, its
officers, employees, agents, affiliates and
representatives of and from any and all claims, suits,
costs and actions brought by any Student, or their
heirs, against company arising out of their
participation in this program or by any patient
claiming that the negligence of Student caused,
compounded or exacerbated their injuries. This
indemnity shall survive and remain enforceable after
the expiration or termination of this Affiliation
Agreement; provided, however, that this indemnity is
not intended to cover claims against Contractor arising
solely out of Contractor's own negligence or
intentional conduct.
6. INSURANCE
termination of this Affiliation Agreement, provided
however, that this indemnity is not intended to cover
claims against Contractor arising solely out of
Contractor's own negligence or intentional conduct.
5.3. Defense Obligation. In any action in which School is
obligated to provide Contractor with a defense, School
shall at its cost and expense, fully and diligently
defend Contractor against any claims brought,
investigations undertaken or actions filed which
concern claims for which Contractor is entitled to
indemnification under paragraphs 5.1, 5 2, and 5.3.
6.1. Professional Medical Liability and General
Liability Coverage. School will maintain
Professional Medical Liability and General Liability
coverage of not less than one million dollars
($1,000,000 00) per occurrence and three million
dollars ($3,000,000 00) aggregate. Coverage must
specifically cover Students in the Field Internship
Experience, working under this agreement and within
the course of their training and education during this
program School will name Contractor as an
Additional Insured under the policy and include an
indemnification provision, by endorsement, to be
attached to the certificate of insurance. School will
provide Contractor with written verification of
coverage in the form of a certificate of insurance,
which will be attached to this agreement School
covenants to keep the required insurance in force and
effect through the term of this agreement and maintain
tail coverage for five (5) years thereafter if the
coverage was a "claims made" policy
2007 NCTI Affiliation Agreement
Confidential and Propnetary
AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE
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6.2. Endorsement for Student Activities. School assures
Contractor that all coverage of insurance required
herein includes specific provisions and/or
endorsements to include Students within School's
Medical Liability and General Liability coverage for
all activities conducted under this program
6.3. Coverage for Student Injuries. School recognizes
that Students are NOT covered by Contractor's
Workers Compensation Insurance or Self Insured
Program. School represents and warrants that It will
maintain, or ensure that its Students are covered, for
bodily injury and disease should any Student be
injured or become ill during the course of their Field
Internship Experience School will provide Contractor
with a written verification of insurance coverage in the
form of a certificate of insurance which will be
attached to this agreement
6.4. Amount of Coverage Not a Limitation. The amount
of insurance required hereunder shall not limit
School's liability nor relieve School of any obligation
hereunder.
6.5. Minimum Qualifications of Insurer. Any policies of
insurance shall be maintained with insurance
companies (i) holding a "General Policyholder's
Rating" of MV or better, as set forth in the most
current issue of "Best's Insurance Guide," or
comparable rating from reputable rating organizations;
(ii) licensed to operate and sell insurance in the state in
which the Field Internship Experience will occur, and
(in) in good standing and admitted, if applicable, with
the state's Department of Insurance or other similar
regulatory agency in the state in which the Field
Internship Experience will occur.
7. NOTICES
7.1. Any notice required or permitted by this Agreement
shall be in writing and shall be delivered as follows,
with notice deemed given as indicated: (a) by personal
delivery, when delivered personally, (b) by overnight
courier, upon written verification of receipt; (c) by
facsimile transmission, upon acknowledgment of
receipt of electronic transmission, or (d) by certified or
registered mail, return receipt requested, upon
verification of receipt. Notice shall be sent to the
following addresses:
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If to Contractor:
10. MISCELLANEOUS.
2007 NCTi Affiliation Agreement
Confidential and Proprietary
AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE
Port Angeles Fire Department
102 East 5th Street
Port Angeles, WA 98362
If to School.
College of Emergency Services, Inc.
333 Sunrise Avenue, Suite 500
Roseville, California 95661
With Mandatory Copy to:
Legal Department
American Medical Response, Inc
6200 South Syracuse Way, Suite 200
Greenwood Village, Colorado 80111
8. Fees, Compensation and Tuition
8.1. Fees, Compensation and Tuition. If applicable, any
fees, compensation and tuition that Contractor shall
receive will be set forth in Exhibit B
9. Scope of Field Internship Experience
9.1. Scope of Field Internship Experience. The specific
scope of the Field Internship Experience that the
Contractor shall provide will be set forth in Exhibit C.
10.1. Miscellaneous. This Agreement (including the
Schedules and Exhibits hereto) (a) constitutes the
entire agreement between the parties with respect to
the subject matter hereof, superseding all prior oral or
written agreements with respect thereto; (b) may be
amended only by written instrument executed by both
parties; (c) may not be assigned by either party
without the written consent of the other party, such
consent not to be unreasonably withheld; (d) shall be
binding on and inure to the benefit of the parties
hereto and their respective successors and permitted
assigns; (e) shall be interpreted and
enforced in accordance with the laws of
the State of Washington, without regard
to the conflict of laws provisions thereof,
5
11. Other.
and the federal laws of the United States
applicable therein; (t) this Agreement may be
executed in several counterparts (including by
facsimile), each of which shall constitute an original
and all of which, when taken together, shall constitute
one agreement, and (g) this Agreement shall not be
effective until executed by both parties. In the event of
a disagreement between this Agreement and any
Schedule hereto, the terms of this Agreement shall
govern
11.1. Compliance with Laws. The parties will comply in
all material respects with all applicable federal and
state laws and regulations including, the federal Anti
kickback statute.
11.2. Compliance Program and Code of Conduct The
Contractor acknowledges that School has made
available to School a copy of its Compliance Program
and Code of Conduct at School's web site, located at
www amr net The School shall comply with any
training requirements that may be legally imposed
upon School by any applicable regulatory authority
11.3. Non Exclusion. Each party represents and certifies
that it has not been convicted of any conduct identified
on Exhibit D. Each party further represents and
certifies that it is not ineligible to participate in
Federal health care programs or in any other state or
federal government payment program, as provided on
Exhibit D or otherwise Each party understands that
if DHHS or OIG excludes it, or any of its employees
who provide health care services, from participation in
Federal health care programs, the party must notify the
other party within 5 days of knowledge of such fact,
and the other party may immediately terminate the
Agreement
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IN WITNESS WHEREOF, the parties have hereto executed
this Agreement
College of E Se es zinc.
By:
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Executive Director, A demic Programs
Port Angeles Fire Department
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Fire Chef Ken Dubuc
2007 NCTI Affiliation Agreement
Confidential and Proprietary
AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE
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AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE
Student is enrolled in a course of study at
School designed to enable Student to become a
licensed/certified Emergency Medical Technician,
Emergency Medical Technician- Paramedic or other similar
pre- Contractor health care provider. As part of the
curriculum, Student has enrolled in the Field Internship
Experience, which is offered through the School, with
Contractor's assistance. The Field Internship Experience
involves 1) Student's performing acquired pre hospital
skills alongside Contractor's personnel; and, 2)
accompanying and observing the Contractor's personnel
providing emergency and non emergency ambulance
transport, care and related services
Student has asked to participate in Field Internship
Experience knowing that participation will require Student
to accompany Contractor personnel in dangerous and
potentially life- threatening situations. Student realizes that
Contractor could not, and would not, allow Student to
accompany its personnel without his/her agreement to (i)
release the Contractor from any and all claims for injury or
death which may result from Student's participation in the
program; (ii) assume the risk of death or injury associated
with the Field Internship Experience; (iii) agree to read,
understand and follow Contractor's policies, procedures
and guidelines; (iv) act in a professional and respectable
manner at all times, and (v) follow the instruction/direction
of Contractor personnel with respect to patient care,
demeanor, safety, use of personal protective devices, etc
Student understands that he or she is exposing himself or
herself to certain risks inherent in the activities associated
with the Field Internship Experience. Student hereby
represents that he or she AGREES TO ASSUME THE
RISKS INHERENT IN THE ACTIVITY. These risks
include, but are not limited to, being hurt or injured. (1) by
broken glass (or other scene hazards) including various cuts
about the head, face, eyes, hands, legs, and torso, (2) by
exposure to tetanus or contagious diseases such as the
Hepatitis B virus and the Human Immunodeficiency Virus
("HIV"), (3) injury due to gurney lifts and or drops; (4)
injury from slip and fall type incidents; (5) various strains
and/or sprains to one and/or all muscle groups, (6) risks
associated with emergency vehicle operation; and (7) risks
2007 NCTI Affiliation Agreement
Confidential and Proprietary
Exhibit A
Student Intern Agreement and Release
7
at the scene of emergencies including assault and battery.
In consideration of Contractor's agreement to provide the
Field Internship Experience to Student, Student agrees to
release and forever discharge Contractor and its agents,
employees affiliates, parent corporation, successors and
assigns of and from all claims, demands, suits, injunes or
damages of any kind arising in any way out of the
participation in this program.
Student further agrees to (i) follow Contractor's policies,
procedures and work rules; (ii) follow Contractor's
instruction and direction with respect to patient care, safety,
personal protection; and, abide by Contractor rules and
direction Student understands that failure to follow the
Contractor's direction may result, in Contractor's sole
discretion, in his/her expulsion from the Field Internship
Experience program.
The School shall require its students to complete a Criminal
Offenders Record Information "CORI check. By virtue
of this agreement, the School assures Contractor that it
found no information that would, in accordance with the
provisions of state EMS regulations, preclude the Student
from the duties of an EMS provider.
The relationship of field internship Student and Contractor
is that of a student being provided an educational
experience by Contractor and such activity shall in no way
be construed as creating any other relationship including an
employment relationship. The Student shall receive no
compensation from Contractor for activities during the
internship.
The Student will comply in all material respects with all
applicable federal and state laws and regulations including,
the federal Anti- kickback statute The Student
acknowledges that School has made available to Student a
copy of its Compliance Program and Code of Conduct at
School's web site, located at www amr net The Student
shall comply with any training requirements that may be
legally imposed upon School by any applicable regulatory
authority.
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AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE
The Student represents and certifies that he /she has not
been convicted of any conduct identified on Attachment
"A" The Student further represents and certifies that he /she
is not ineligible to participate in Federal health care
programs or in any other state or federal government
payment program, as provided on Attachment "A" or
otherwise. The Student understands that if DHHS or OIG
excludes he /she from participation in Federal health care
programs, he /she must notify the School and Contractor
within 5 days of knowledge of such fact, and the Contractor
may immediately terminate the Agreement.
Student certifies that he /she is at least eighteen (18) years
old and is an adult with full legal authority to execute this
release.
By Signing this Document You Acknowledge That You
Have Been Advised That There Are Risks Inherent in this
Type of Activity and Have Decided to Assume That Risk
and Release the Company of and from All Liability. You
Agree to Release the Company from Any Claims
Associated with the Event and That You, Not the
Company, Are Assuming Complete and Total
Responsibility for and Any and All Injuries, Damages or
Losses That You May Suffer as a Result of Participating
in the Field Internship Experience Program.
I agree to all terms set forth above.
Dated
Signature of Student:
Print Name
Attachment "A"
Overview of law regarding exclusion from
Medicare and State Health Care Programs
42 U.S.C. 1320a -7
(a)
Mandatory exclusion. The Secretary shall
exclude the following individuals and entities from
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Confidential and Proprietary
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participation in any Federal health care program (as defined
in section 1320a -7b(f) of this title)
(1) Conviction of program- related crimes.
Any individual or entity that has been convicted of a
criminal offense related to the delivery of an item or service
under subchapter XVIII of this chapter or under any State
health care program
(2) Conviction relating to patient abuse.
Any individual or entity that has been convicted, under
Federal or State law, of a criminal offense relating to
neglect or abuse of patients in connection with the delivery
of a health care item or service
(3) Felony conviction relating to health
care fraud. Any individual or entity that has been
convicted for an offense which occurred after August 21,
1996, under Federal or State law, in connection with the
delivery of a health care item or service or with respect to
any act or omission in a health care program (other than
those specifically described in paragraph (1)) operated by
or financed in whole or in part by any Federal, State, or
local government agency, of a criminal offense consisting
of a felony relating to fraud, theft, embezzlement, breach of
fiduciary responsibility, or other financial misconduct
(4) Felony conviction relating to controlled
substance Any individual or entity that has been convicted
for an offense which occurred after August 21, 1996, under
Federal or State law, of a criminal offence consisting of a
felony relating to the unlawful manufacture, distribution,
prescription, or dispensing of a controlled substance.
(b) Permissive exclusion. The Secretary may
exclude individuals and entities from participation in any
Federal health care program. These Permissive Exclusions
are for misdemeanors of the above (see 42 USC 1320a-
7(b)(1-15)) offenses plus other infractions that shall be
determined on an individual case -by -case basis
(NOTE: the DHHS and OIG list of excluded
individuals /entities is available through the Internet at
http: /www.hhs.gov /oig), and an overview of the
exclusion regulations is attached hereto).
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2007 NCTI Affiliation Agreement
Confidential and Proprietary
AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE
Exhibit B
Fees, Compensation and Tuition
Neither party to this agreement shall receive any fees, compensation, or tuition from the other party for the provision of
any services pursuant to the terms hereof.
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Performs a
primary
assessment and
intervenes as
necessary
Asks appropriate
questions,
specific to patient
chief complaint
Obtains patient
history,
medications and
allergies
2007 NCTI Affiliation Agreement
Confidential and Proprietary
AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE
Exhibit C
Scope of Field Internship Experience
Clinical Performance Standards
The following performance evaluation standards have been developed as an objective
measurement of the intern's performance. These standards are to be utilized when
completing the intern's evaluations. Interns are expected to achieve a "3" rating in every
rating factor on the final major evaluation in order to be eligible for internship.
EVALUATION
FACTOR
RATING 1 RATING 2
ASSESSMENT /PATHOLOGIES
Assessment and Interventions
Unable to perform a
complete or
organized primary
assessment without
prompting. Omits
portions of the
assessment and /or
fails to recognize
findings or
intervene
appropriately.
Fails to ask details
specific to chief
complaint; rambles
or does not appear
to have a focus to
the questions.
Does not obtain
pertinent
information; is
incomplete or
inaccurate.
10
Performs a
complete primary
assessment, but is
either slow or
disorganized and
inconsistent in
recognizing findings
or intervening
appropriately.
Asks questions
specific to the chief
complaint but is
either slow or
disorganized.
Obtains an
adequate patient
assessment but is
either slow in
assessing and /or
disorganized.
RATING 3
Independently
performs a complete
and organized
assessment in a
timely manner,
recognizes findings
and intervenes
appropriately in a
timely manner.
Asks questions
pertinent to the chief
complaint;
deliberate and
timely.
Obtains an
adequate patient
history, medications
and allergies in a
fairly organized and
timely manner.
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44 ,NSTRUCTION
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AFFILIATION AGREEMENT FOR FIELD INTERNSHIP EXPERIENCE
Exhibit D
Overview of law regarding exclusion from
Medicare and State Health Care Programs
42 U.S.C. 1320a -7
(a) Mandatory exclusion. The Secretary shall exclude the following individuals and entities from participation in any
Federal health care program (as defined in section 1320a -7b(f) of this title):
(1) Conviction of program- related crimes. Any individual or entity that has been convicted of a criminal offense
related to the delivery of an item or service under subchapter XVIII of this chapter or under any State health care program.
(2) Conviction relating to patient abuse. Any individual or entity that has been convicted, under Federal or State
law, of a criminal offense relating to neglect or abuse of patients in connection with the delivery of a health care item or service.
(3) Felony conviction relating to health care fraud. Any individual or entity that has been convicted for an
offense which occurred after August 21, 1996, under Federal or State law, in connection with the delivery of a health care item or
service or with respect to any act or omission in a health care program (other than those specifically described in paragraph (1))
operated by or financed in whole or in part by any Federal, State, or local government agency, of a criminal offense consisting of
a felony relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct.
(4) Felony conviction relating to controlled substance. Any individual or entity that has been convicted for an
offense which occurred after August 21, 1996, under Federal or State law, of a criminal offence consisting of a felony relating to
the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.
(b) Permissive exclusion. The Secretary may exclude individuals and entities from participation in any Federal health
care program. These Permissive Exclusions are for misdemeanors of the above (see 42 USC 1320a- 7(b)(1 -15)) offenses plus
other infractions that shall be determined on an individual case -by -case basis
(NOTE: the DHHS and OIG list of excluded individuals /entities is available through the Internet at
http: /www.hhs.gov /oig), and an overview of the exclusion regulations is attached hereto).
2007 NCTI Affiliation Agreement
Confidential and Proprietary
11