HomeMy WebLinkAbout2016-724-E Emergency Svc - Durham Tech Site Affiliation AgreementPageͳ
AFFILIATION AGREEMENT
BETWEEN
DURHAM TECHNICAL COMMUNITY COLLEGE
Emergency Medical Science Program
AND
Orange County Emergency Services
This contract made and entered into this 6th day of April, 2016 between Orange
County, a local political subdivision of the State of North Carolina, by and through its
Emergency Services Department (hereinafter referred to as the “Agency”) and Durham
Technical Community College (hereinafter referred to as the “College”).
WITNESSETH
WHEAREAS, the Agency desires to provide a clinical setting for EMS students to
train, experience, and enhance their PROGRAM skills, and
WHEREAS, the College wishes to send certain EMS students to the Agency for
additional training,
NOW THEREFORE, in consideration of the covenants set forth, the Agency and the
College agree as follows:
Responsibilities of Agency
1. The Agency agrees to provide clinical facilities suitable for the fulfillment of the
objectives of the EMS program.
2. The Agency will provide a coordinator to regularly communicate with the College
regarding numbers of students, clinical assignments (including days and hours), and all
other details to ensure the smooth operation of the program.
3. The Agency agrees that all patient care activities are the responsibility of the Agency.
4. The agency agrees to provide preceptors to oversee all actions of the student.
5. The Agency agrees to provide, if needed and when available, adequate and suitable
classrooms, conference rooms, and other teaching space adequate for the students'
clinical experience.
6. The Agency will permit and encourage College representatives, its faculty and students
to participate in orientation sessions in connection with the clinical experience as
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required by the agency.
7. The Agency agrees to share all appropriate information with the College regarding both
patients and services in order for the students to perform their professional services.
8. The students assigned to the Agency will not be eligible for financial compensation
during the practical training within the Agency (wages, salaries, worker’ compensation,
etc)
9. The Agency agrees that no tuition or fees for clinical training shall be collected from the
students.
The College's Responsibilities
1. That the College will make arrangement for professional liability coverage in the
amounts of $2,000,000 per occurrence, $5,000,000 per aggregate for the acts and
omissions of the EMS Program faculty members and students. The College will provide
a certificate of insurance to the Agency.
2. The College agrees that the student and the faculty members are not agents, servants, or
employees of the Agency. The student assigned to the Agency and College faculty will
not be eligible for financial compensation during the practical training within the
Agency (wages, salaries, worker’ compensation, etc.).
3. The College is responsible for assuring that students have a satisfactory health appraisal
on file, including, but not limited to, a negative PPD test on file (Current within 1 year)
or proof of a negative TB screening for positive PPD reactors, and Hepatitis B vaccine
or Hepatitis B waiver.
4. The College will appoint a coordinator to act as a liaison with the Agency’s coordinator
to arrange for clinical rotations, student assignments, and other details to effectuate the
goals of the program.
5. The College, its faculty and students, agree to review and abide by the Agency’s
institutional policies, profession protocols, and bylaws.
6. The College insures that each faculty member who is supervising a student's practice is
qualified under the requirements of the College and is currently licensed in North
Carolina.
7. The College agrees that (if required by the Agency) a state criminal background check
and/or drug screening be conducted on all students and Faculty to be assigned to the
Agency under this Agreement. Such criminal background check shall be conducted in
all states where the assigned Student or Faculty has lived, worked, or gone to school
from the date the assigned individual turned eighteen (18) years of age. The criminal
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background check will include both felonies and misdemeanor. The National Sex
Offender Registry is included in the criminal background check. The drug test is a 12-
panel urine screen report from a National Institute of Drug Abuse-approved laboratory.
The student and/or Faculty will pay for the conducting of the criminal background
check and drug screening directly with (Certified Background) the provider of this
service selected by the College in accordance with the procedures established by the
College. In return, the person responsible for receiving the results at the Agency will be
giving a password directly from Certified Background to view the reports and determine
then acceptable or not for the clinical experience. The Agency will contact the College
by email with their answer directly to the EMS Program Clinical Coordinator, the
person responsible for receiving the results at the College. The Agency reserves the
right not to accept any student who has a criminal record or positive drug screening into
the clinical training program. The Agency understands that the College may not receive,
transmit nor retain copies of the criminal background check or drug screening results.
The Agency understands that students with positive results that are denied clinical
placement are allowed one appeal. The Agency agrees to review that appeal and to
contact the College by email with their answer. The college will not provide specific
information to students regarding which clinical agencies accept or deny access to
clinical placement without expressed permission from the clinical agency. The Agency
agrees to hold the College harmless for nay claims that might arise from the Agency’s
use or reliance on CBC or drug screening information.
Miscellaneous
1. This agreement shall begin on March 1, 2016 and run to the February 28, 2017. This
agreement shall automatically renew from year to year. The agreement may be
terminated by either party provided written notice of termination is furnished to the
other party at least three (3) months prior to such termination. The contract shall
nevertheless remain in force as affecting any student in the program until the student
has completed his/her course of instruction.
2. The College will provide an exposure control plan and guidelines for its faculty and
students in accordance with OSHA Standards for Bloodborne Pathogens. In the event
of exposure incidents involving College faculty or students during clinical training
within the Agency’s facilities, the Agency agrees to assist the College in providing
appropriate post-exposure evaluation and follow-up as required by the OSHA standards
and the College's Exposure Control Plan. The College will reimburse or cover the costs
of exposure incidents and follow-ups resulting from acts or omissions of faculty
employed by the College to the extent permitted by law. Students will be responsible
for all costs incurred during their post-evaluation and follow-up. The College will
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provide a copy of its exposure control plan and guidelines to the Agency upon request.
3. The Agency retains full authority and responsibility for the care and treatment of its
patients and will have administrative and professional supervision of any college
students while said students are involved in clinical training within the Agency under
this contract. The Agency reserves the right to dismiss from the clinical experience any
students or faculty for reasons of misconduct or failure to follow rules and regulations.
Reasons for such action will be furnished to the College in writing.
4. This agreement contains the entire understanding of the parties and shall not be altered,
amended, or modified except by an agreement in writing executed by the duly
authorized officials of both parties.
5. The laws of North Carolina shall govern the validity and interpretation of the
provisions, term, and conditions of the Agreement.
6. The Agency herby agrees with the College that, in its educational practices, it will
comply with any such non-discrimination laws as may be applicable to it in the
performance of this Agreement without regard to race, national origin, age, sex,
religion, disability or genetic information.
Indemnification
The Agency understands that the College has governmental immunity which it has not
statutory authority to waive except to the extent that it is insured. For that reason, except
as to matters and things covered by insurance as set out herein, the College agrees to
protect or indemnify the Agency against claims, injuries, damages, or the like.
Privacy
Agency and College acknowledge that as a condition of participation in this training
experience, Students are required to maintain protected health information of the
patients in accordance with the Health Insurance Portability and Accountability Act of
1996, and all applicable regulations promulgated hereunder (collectively, "HIPAA"),
including information obtained through use of computer systems. Agency shall educate
Students regarding its confidentiality and privacy policies and procedures. Agency and
the College shall instruct Students that information regarding patients shall be held in
confidence, all protected health information regarding Agency patients shall be
maintained by Student in compliance with HIPAA, Students shall not make copies of
patient records and Students shall not identify patients or any protected health
information in any papers, reports or case studies provided to College without first
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obtaining permission of the Agency and complying with Agency’s confidentiality and
privacy policies and procedures. The College shall not request Students to identify
patients or any protected health information in any papers, reports or case studies
provided to College without first obtaining permission of the Agency and complying
with confidentiality, privacy and security policies and procedures.
The College will comply with the applicable HIPAA requirements and, in the event that
the Agency determines that some or all of the activities performed by Students and,
through supervision of Students, the College, would cause the College to meet the
definition of a “business associate” of the Agency under HIPAA, the College
understands that it will be asked to execute such agreements and practices as the
Hospital may require to ensure compliance, including the execution of a Business
Associate Agreement between the Agency and the College. Activities within the scope
of this Agreement which may cause the college to be considered a “business associate”
of the Agency under HIPAA include, but are not limited to, the College sending Faculty
to provide clinical instruction and supervision for students in the Hospital setting, or the
College requesting and/or receiving from Students Protected Health Information, as
defined in the HIPAA Privacy Rule, which has been disclosed during the clinical
instruction.
[SIGNATURE PAGE TO FOLLOW]
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SIGNATURE PAGE
IN WITNESS WHEREOF, the parties have set their hands and seals.
_________________________________________ ________________________
Dinah Jeffries Date
Interim Emergency Services Director
Orange County Emergency Services
_________________________________________ ________________________
Kim Woodward Date
EMS Operations Manager
Orange County Emergency Services
_________________________________________ ________________________
Peter Wooldridge Ph.D Date
Vice President for Corporate and Continuing Education
Durham Technical Community College
_________________________________________ ________________________
Randall J. Egsegian, Ph.D. Date
Dean and Department Head
Public Safety Department
Durham Technical Community College
_________________________________________ ________________________
John M. Deal, MHS Date
Program Director, Emergency Medical Science Program
Durham Technical Community College
DocuSign Envelope ID: FF596EF9-95C3-43F0-9E5B-F05288BBF843
DocuSign Envelope ID: FF596EF9-95C3-43F0-9E5B-F05288BBF843 ZOVIDERS SERVICE
Cf#A ORGANIZATION PURCHASING GROUP mnso
Certificate of Insurance
nurses service ur�niza[iun--
OCCURENCE POLICY FORM Print Date: 9/25/2015
Producer Branch Prefix Policy Number Policy Period
018098 970 HPG 0127265153 from 10101115to 10101I16at 12:01 AM Standard Time
Named Insured and Address: Program Administered by:
Durham Technical Community College Nurses Service Organization
1637 E Lawson St 159 E. County Line Road
Durham, NC 27703-5023 Hatboro, PA 19040-1218
1-800-986-4627
www.nso.com
Medical Specialty: Code: Insurance is provided by:
School Blanket-Healthcare Provider Students 80998 American Casualty Company of Reading, Pennsylvania
333 S. Wabash Avenue, Chicago, IL 60604
Professional Liability $2,000,000 each claim $5,000,000 aggregate
Your professional liability limits shown above include the following:
Personal Injury Liability
Coverage Extensions
Grievance Proceedings $ 1,000 per proceeding $ 10,000 aggregate
Defendant Expense Benefit $ 10,000 aggregate
Deposition Representation $ 1,000 per deposition $ 5,000 aggregate
Assault $ 1,000 per incident $25,000 aggregate
Medical Payments $ 2,000 per person $ 100,000 aggregate
First Aid S 500 per incident $25,000 aggregate
Damage to Property of Others $ 250 per incident $ 10,000 aggregate
Total: $22,162.00
Base Premium $22,162.00
Policy Forms& Endorsements(Please see attached list for a general description of many common policy forms and
endorsements.)
G-144918-A CNA79561 G-144931-A32 G-144932-A32 G-144922-A
Keep this document in a safe place.It
and proof of payment are your proof
coverage, There is no coverage in force
unless the premium is paid in full In order
to activate your coverage,please remit
Chairman of the Board Secretary premium in full by the effective date of
this Certificate of Insurance,
Master Policy#188711433
G-141241-B(03/2010) Coverage Change Date: Endorsement Change Date:
DocuSign Envelope ID: FF596EF9-95C3-43F0-9E5B-F05288BBF843
Compensation and Other disclosure Information
Healthcare Providers Service Organization(HPSO)a registered trade name of Affinity Insurance Services,Inc.,exclusively offers the
HPSO Program as an agent of CNA and provides services that may include the following-program marketing,underwriting,policy
management,billing,risk management and client services on its behalf,
Affinity Insurance Services Inc.is an insurance producer licensed in your state.Insurance producers are authorized by their license to
confer with insurance purchasers about the benefits,terms and conditions of insurance contracts;to offer advice concerning the
substantive benefits of particular insurance contracts;to sell insurance;and to obtain insurance for purchasers.The role of the producer
in any particular transaction involves one or more of time activities.Compensation will be paid to the producer,based on the insurance
contract the producer sells.Depending on the insurer(s)and insurance contract(s)the purchaser selects,compensation will be paid by
the insurer(s)selling the insurance contract or by another third party.Such compensation may vary depending on a number of factors,
including the insurance contract(s)and the insure(s)the purchaser selects.In addition,Affinity may charge a fee for administrative
services.Your signature on your application,quote form,check,and/or other authorization for payment of your premium,will be
deemed to signify your consent to and acceptance of the terms and conditions including the compensation,as disclosed above,that is to
be received by Aon.The insurance purchaser may obtain information about compensation expected to be received by the producer
based in whole or in part on the sale of insurance to the purchaser,and compensation expected to be received based in whole or in part
on any alternative quotes presented to the purchaser by the producer,by contacting member services at 1-800-9864627.
In addition,premiums paid by Clients to Affinity for remittance to insurers,Client refunds and claim payments paid to Affinity by
insurance companies for remittance to Clients are deposited into fiduciary accounts in accordance with applicable insurance laws until
they are due to be paid to the insurance company or Client. Subject to such laws and the applicable insurance company's consent,
where required,Affinity will retain the interest or investment income earned while such funds are on deposit in such accounts.
In placing,renewing,consulting on or servicing your insurance coverages Affinity and its affiliates may participate in contingent
commission arrangements with insurance companies that provide for additional contingent compensation,if,for example,certain
underwriting,profitability,volume or retention goals are achieved.Such goals are typically based on the total amount of certain
insurance coverages placed by Aon with the insurance company or the overall performance of the policies placed with that insurance
company,not on an individual policy basis.As a result,Aon may be considered to have an incentive to place your insurance coverages
with a particular insurance company.
Our liability to you,in total, for the duration of our business relationship for any and all damages,costs,and expenses(including but
not limited to attorneys'fees),whether based on contract,tort(including negligence),or otherwise,in connection with or related to our
services(including a failure to provide a service)that we provide in total shall be limited to the lesser of S6,000,000 or the singular
annual limit of the policy of insurance procured by us on your behalf from which your damages arise.
This liability limitation applies to you,our client,and extends to our client's parent(s),affiliates,subsidiaries,and their respective
directors,officers,employees and agents(each a"Client Group Member"of the"Client Group' wherever located that seek to assert
claims against ARS,and its parent(sX affiliates,subsidiaries and their respective directors,officers,employees and agents(each an
"Aon Group Membee'of the"Aon Group"). Nothing in this liability limitation section implies that any Aon Group Member owes or
accepts any duty or responsibility to any Client Group Member.
If you or any of your Group Members asserts any claims or makes any demands against us or any Aon Group Member for a total
amount in excess of this liability limitation,then you agree to indemnify ARS for any and all liabilities,costs,damages and expenses,
including attorneys'fees,incurred by AILS or any Aon Group Member that exceeds this liability limitation.
Aon Corporation,our ultimate parent company,and its affiliates have from time to time sponsored and invested in insurance and
reinsurance companies. While we generally undertake such activities with a view to creating an orderly flow of capacity for our clients,
we also seek an appropriate return on our investment. These investments,for which Aon is generally at-risk for potential price loss,
typically are small and range from fixed-income to common stock transactions. In such case,the gains or losses we make through your
investments could potentially be linked,in part,to the results of treaties or policies transacted with you. Please visit the Aon website at
httn://www non.com/market relationshiM for a current listing of insurance and reinsurance carriers in which Aon Corporate and its
affiliates hold any ownership interest.
FATCA Notice:Please go to www.aon.com/FATCA to obtain the appropriate W-9.
DocuSign Envelope ID: FF596EF9-95C3-43F0-9E5B-F05288BBF843
SCHOOL POLICY FOR HEALTHCARE PROVIDER STUDENTS
Agreement to Provide Notice of Cancellation
In consideration of the premium paid, it is agreed that if the policy to which this endorsement is attached
is cancelled before the expiration date, we will endeavor to mail notice to the person or entity named
below. However, failure to mail such notice shall impose no obligation or liability of any kind upon the
company, its agents or representatives.
Person or Entity Name and Address:
Northgate Associates
PO Box 2476
Durham, NC 27715
This endorsement is a part of the policy and takes effect on the effective date of the policy, unless
another effective date is shown below. All other provisions of the policy remain unchanged.
Must Be Completed Complete Only When This Endorsement is Not Prepared with the Policy
Or is Not to be Effective with the Polio
ENDT. NO. POLICY NO. ISSUED TO ENDORSEMENT EFFECTIVE DATE
01 1 0127265153 Durham Technical Community College 10/01/2015
G-144M-A(1/2003)
AMERICAN CASUALTY COMPANY OF READING, PA Page 1 of 1