HomeMy WebLinkAboutC2011-366 - 9/5/2011 - NAHOSPITAL AFFILIATION AGREEMENT
This HOSPITAL AFFILIATION AGREEMENT (the "Agreement ") is made as of th is 1 st day of August 2011 by and
between DRISCOLL CHILDREN'S HOSPITAL, whose address is 3533 South Alameda, Corpus Christi, Texas 78411
(hereinafter referred to as "Hospital ") and City of Corpus Christi whose address is 1201 Leopard Street, Corpus
Christi, Texas 78401 (hereinafter referred to as "Entity ").
WITNESSETH:
WHEREAS, Hospital offers to enrolled students a degree and/or certification program in the field(s) of
certain health science programs; and
WHEREAS, Entity operates a Mobile Intensive Care Unit; and
. WHEREAS, Hospital desires to provide to its students a clinical learning experience through the
application of knowledge and skills in actual patient - centered situations in a mobile intensive care unit; and
WHEREAS, Entity agrees to make its facility available to Hospital for such purposes.
Now, THEREFORE, in consideration of the mutual promises contained herein, the parties hereby
agree as follows:
1. RESPONSIBILITIES OF HOSPITAL.
(a) Clinical Program Hospital shall be responsible for the implementation and operation of the clinical
component of its programs at Entity, which programs shall be approved in advance by Entity. This Agreement
shall cover certain clinical programs, which shall include EMT and paramedic (collectively, referred to as the
"Program "). Such responsibilities shall include, but not limited to, the following:
(i) Orientation of students to the clinical experience at Entity;
(ii) Provision of classroom theory and practical instruction to students prior to their clinical
assignments at Entity;
(iii) Provide adequate documentation attesting to the competency of each student prior to
performing clinical rotations;
(iv) Preparation of student/patient assignments and rotation plans for each student and
coordination of same with Entity;
(v) Continuing oral and written communication with Entity regarding student performance and
evaluation, absences and assignments of students, and other pertinent information;
(vi) Supervision of students and their performance at Entity;
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Driscoll Children's Hospital INDEXED
(vii) Participation, with the students, in Entity's Quality Assurance and related programs;
(viii) Performance of such other duties as may from time to time be agreed to between Hospital
and Entity; and
(ix) Provide adequate documentation attesting to competency of each instructor.
All students, faculty, employees, agents and representatives of Hospital participating in the Program
at Entity (the "Program Participants ") shall be accountable to the Entity's Administrator.
(b) Student Statements Hospital shall require each Program Participant to sign a Statement of
Responsibility, in the form attached hereto as Exhibit A , and a Statement of Confidentiality and Security, in
the form attached hereto as Exhibit B.
(c) Insurance Hospital shall obtain, maintain and provide proof to Entity, or shall require each
individual Program Participant to obtain, maintain and provide proof to Entity, occurrence -type general and
professional liability insurance coverage in amounts not less than $1,000,000 per occurrence and $3,000,000
annual aggregate per Program Participant, with insurance carriers or self insurance programs approved by
Entity and covering the acts and omissions of Program Participants. If such coverage is provided on a claims -
made basis, then such insurance shall continue throughout the term of this Agreement and upon the
termination of this Agreement, or the expiration or cancellation of the insurance, Hospital shall purchase, or
shall require each individual Program Participant to purchase, tail coverage for a period of three years after the
termination of this Agreement or the expiration or cancellation of the claim -made coverage (said tail coverage
shall be in amounts and type equivalent to the claims -made coverage). Hospital shall further, at its expense,
obtain and maintain workers' compensation insurance and unemployment insurance for Hospital employees
assigned to Entity. For all insurance required by this Paragraph 1(c), Hospital shall require the insurance
carrier notify Entity at least thirty (30) days in advance of any cancellation or modification of such insurance
policy and shall provide to Entity certificates of insurance evidencing the above coverage and renewals thereof.
(d) Health of Program Participants All Program Participants shall pass a medical examination
acceptable to Entity prior to their participation in the Program at Entity at least once a year or as otherwise
required by state and federal law. The Program Participants, whom are not employed by Hospital, shall
provide to Hospital and Entity prior to Program enrollment, proof of Program Participant's Health Insurance
Coverage which shall be current and valid throughout the Program. Proof of Health Insurance must include,
but not limited to Participant's Name, PolicylGroup Number, Dates of Coverage, Insurance Provider and
Provider's contact information. Prospective Program Participants who do not provide proof of such Health
Insurance Coverage shall not be accepted into the Program. Program Participant shall be responsible for
arranging for the Program Participant's medical care and/or treatment, if necessary, including transportation
in case of illness or injury while participating in the Program at Entity. In no event shall Entity be financially or
otherwise responsible for said medical care and treatment. Hospital shall complete Attestation Form, in the
form attached hereto as Exhibit C, which includes Program Participants' health records on the following:
(i) Tuberculin skin test within the past 12 months or documentation as a previous positive
reactor with a chest x -ray taken within the past five (5) years and an "Annual Tuberculosis
Health Questionnaire" within the past 12 months; and
(ii) Proof of Rubella and Rubeola immunity by positive antibody titers or 2 doses of MMR; and
(iii) Varicella immunity, by positive history of chickenpox or proof of Varicella immunization; and
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(iv) Proof of Hepatitis B immunization or completion of a certification of declination of vaccine, if
patient contact is anticipated;
(v) Proof of annual influenza vaccination.
Hospital shall provide a complete Attestation Form for each Program Participant one week prior
such Program Participant's educational experience at Entity. A Program Participant will not be allowed to
commence experiences at Entity until such Attestation Form has been completed and provided to the Entity.
(e) Dress Code; Breaks Hospital shall require the students to dress in accordance with dress and
personal appearance standards approved by Hospital. Such standards shall be in accordance with Entity's
standards regarding same. All Program Participants shall remain on the Entity premises for breaks, including
meals. Program Participants shall pay for their own meals at Entity.
(f) Performance. All faculty provided by Hospital shall be duly licensed, certified or otherwise qualified
to participate in the Program at Entity. Hospital shall have a specially designated staff for the performance
of the services specified herein. Hospital and all Program Participants shall perform its and their duties and
services hereunder in accordance with all relevant local, state, and federal laws and shall comply with the
standards and guidelines of all applicable accrediting bodies, including but not limited to JCAHO, and the
bylaws, rules and regulations of Entity and any rules and regulations of Hospital as may be in effect from
time to time. Neither Hospital nor any Program Participant shall interfere with or adversely affect the operation
of Entity or the performance of services therein.
(g) Background Checks Hospital shall, in a timely manner at either Hospital's expense or the
Program Participant's expense, conduct (or have conducted) a background check on each and every student
assigned to the Program and, on an annual basis, every member of the staff/faculty responsible for
supervision and/or instruction. The background check shall include, at a minimum, the following:
(i) Social Security number verification;
(ii) 7 -year Multi- County Felony and Related Misdemeanor Criminal Record search;
(iii) Two standard employment history references (if applicable);
(iv) HHS /01G/Texas HHS List of Excluded Individuals /Entities - GSA List of Parties Excluded
from Federal Programs;
(v) Education verification (highest degree received);
(vi) If applicable, professional licensure verification and professional disciplinary action check;
(vii) If applicable, certification /designation checks.
Should the background check disclose adverse information as to any student and/or member of the
staff/faculty, Hospital shall immediately contact the Entity. The Entity will look at the adverse information on a
case by case basis. Hospital represents and warrants that Program Participants participating hereunder: (i) are
not currently excluded, debarred, or otherwise ineligible to participate in the Federal health care programs as
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defined in 42 U.S.C. Section 1320a -7b(f) (the "Federal health care programs "); (ii) are not convicted of a criminal
offense related to the provision of health care items or services but has not yet been excluded, debarred or
otherwise declared ineligible to participate in the Federal health care programs, (iii) are not under
investigation or otherwise aware of any circumstances which may result in the Hospital or a Program
Participant being excluded from participation in the Federal health care programs, and (iv) are not convicted of
assaultive and harassment crimes, theft or other crimes of dishonesty, sexual abuse or prostitution offenses,
or crimes relating to alcohol or drug abuse. This shall be an ongoing representation and warranty during the
term of this Agreement and the Hospital shall immediately notify Entity of any change in status of the
representation and warranty set forth in this section. Any breach of this Paragraph 1(h) shall give Entity the
right to immediately terminate this Agreement for cause.
(h) Bloodborne Pathogens. Hospital will ensure that all Program Participants who may be at risk
for occupational exposure to blood or other potentially infectious materials will be:
(i) Trained in accordance with the Occupational Safety and Health Administration's (OSHA)
Occupational Exposure to Bloodborne Pathogens (as published in Friday, December 6, 1991
Federal Register) and any amendments thereto;
(ii) Trained in the modes of transmission, epidemiology and symptoms of Hepatitis B virus (HBV)
and Human Immunodeficiency Virus (HIV) and other bloodborne pathogens;
(iii) Trained in the methods of control that prevent or reduce exposure including universal
precautions, appropriate engineering controls, work practices and personal protective
equipment;
(iv) Provided information on the Hepatitis B vaccine, its efficacy, safety, method of administration
and benefits of being vaccinated; and
(v) Provided proper follow -up evaluation following any exposure incident.
2. RESPONSIBILITIES OF ENTITY.
(a) Access for Program Participants. Entity may accept the Program Participants assigned to the
Program by Hospital provided that Program Participants have met all requirements set forth by Entity and
reasonably cooperate in the orientation of all Program Participants to Entity. Entity agrees to provide
reasonable opportunities for such Program Participants, who shall be supervised by Hospital and Entity, to
observe and assist, unless patient refuses to allow Program Participant participation, in various aspects of
patient care to the extent permitted by applicable law and without disruption of patient care or Entity
operations. Entity shall coordinate Hospital's rotation and assignment schedule with its own schedule and
those of other educational institutions. Entity shall at all times retain ultimate control of the Entity and
responsibility for patient care.
(b) Assistance with Program Evaluations Upon the request of Hospital, Entity agrees to assist
Hospital in the evaluation of each Program Participant's performance in the Program. However, Hospital shall
at all times remain solely responsible for the evaluation and grading of Program Participants.
3. MUTUAL RESPONSIBILITIES. The parties shall cooperate to fulfill the following mutual responsibilities:
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(a) Student Status Students shall be treated as trainees who have no expectation of receiving
compensation or future employment from the Entity or the Hospital.
(b) Courtesy Appointments Any courtesy appointments to faculty or staff by either the Hospital or
Entity shall be without entitlement of the individual to compensation or benefits for the appointed party.
(c) Orientation Entity will provide orientation material to the Hospital educational facility to conduct
orientation for all students and Program Participants on the following: HIPAA, Entity policies and procedures
(including patient safety and infection control), cultural diversity and sensitivity, rights of patients and ethical
aspects of care, treatment and services and process used to address ethical issues and federal or state
regulatory requirements.
4. WITHDRAWAL OF PROGRAM PARTICIPANTS.
Entity may request Hospital to withdraw or dismiss a student or other Program Participant from the Program
at Entity for the following reasons: (i) when his or her clinical performance is unsatisfactory to Entity; (ii) when his
or her behavior, in Entity's discretion, is disruptive or detrimental to Entity and/or its patients; (iii) when the Entity
determines that the student or other Program Participant has violated the rules and regulations of the Entity; or
(iv) when the student or other Program Participant has disclosed information that is confidential by law. In such
event, Program Participant's participation in the Program at Entity shall immediately cease.
INDEPENDENT CONTRACTOR; NO OTHER BENEFICIARIES.
The parties hereby acknowledge that they are independent contractors, and neither the Hospital nor any of its
agents, representatives, Program Participants, or employees shall be considered agents, representatives, or
employees of Entity. In no event shall this Agreement be construed as establishing a partnership or joint venture or
similar relationship between the parties hereto. Hospital shall be liable for its own debts, obligations, acts and
omissions, including the payment of all required withholding, social security and other taxes or benefits. No
Program Participant shall look to Entity for any salaries, insurance or other benefits. No Program Participant or
other third person is entitled to, and shall not, receive any rights under this Agreement.
6. NON - DISCRIMINATION.
There shall be no discrimination on the basis of race, national origin, religion, creed, sex, age, veteran
status, or disability in either the selection of students for participation in the Program, or as to any aspect of the
clinical training; provided, however, that with respect to disability, the disability must not be such as would, even
with reasonable accommodation, in and of itself preclude the Program Participant's effective participation in the
Program.
7, INDEMNIFICATION.
To the extent permitted by applicable law and without waiving any defenses, Hospital shall indemnify and
hold harmless Entity and its subsidiaries, officers, directors, medical and nursing staff, representatives, agents and
employees from and against all liabilities, claims, damages and expenses, including reasonable attorneys' fees,
relating to or arising out of any act or omission of the Hospital or any of its faculty, Program Participants, agents,
representatives and employees under this Agreement, including, but not limited to, claims for personal injury,
professional liability, or with respect to the failure to make proper payment of required taxes, withholding,
employee benefits or statutory or other entitlements.
Affiliation .Agreement, Revised March 2014
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To the extent permitted by law and without waiving any defenses, Entity shalt indemnify and hold
harmless Hospital and its subsidiaries, agents and employees, but not the Program Participants, from and
against all liabilities, claims, damages and expenses, including reasonable attorneys' fees, relating to or
arising out of any act or omission of the Entity under this Agreement.
CONFIDENTIALITY.
Hospital and its agents, Program Participants, faculty, representatives and employees agree to keep
strictly confidential and hold in trust all confidential information of Entity and/or its patients and not disclose or
reveal any confidential information to any third party without the express prior written consent of Entity.
Hospital shall not disclose the terms of this Agreement to any person who is not a party to this Agreement,
except as required by law or as authorized by Entity. Unauthorized disclosure of confidential information or of
the terms of this Agreement shall be a material breach of this Agreement and shall provide Entity with the
option of pursuing remedies for breach, or, notwithstanding any other provision of this Agreement,
immediately terminating this Agreement upon written notice to Hospital.
9. TERM; TERMINATION.
(a) Initial Term The initial term of this Agreement shall be three (3) year(s), commencing on
August 1St, 2011 and ending on July 31 2014.
(b) Termination Except as otherwise provided herein, either party may terminate this Agreement at
any time without cause upon at least ninety (90) days prior written notice, provided that all students
currently enrolled in the Program at Entity at the time of notice of termination shall be given the
opportunity to complete their clinical Program at Entity, such completion not to exceed six (6)
months. Either party may terminate this Agreement effective immediately, upon written notice to
the other party, if there has been a material breach of this Agreement and the party fails to cure the
breach within 30 days after receiving written notice of the breach.
10. ENTIRE AGREEMENT.
This Agreement and its accompanying Exhibits set forth the entire Agreement with respect to the subject
matter hereof and supersedes all prior agreements, oral or written, and all other communications between the
parties relating to such subject matter. This Agreement may not be amended or modified except by mutual
written agreement. All continuing covenants, duties and obligations herein shall survive the expiration or
earlier termination of this Agreement.
11. SEVERABILITY.
If any provision of this Agreement is held to be invalid or unenforceable for any reason, the remaining
provisions of this Agreement shall remain in full force and effect in accordance with its terms disregarding
such unenforceable or invalid provision.
12. CAPTIONS.
The captions contained herein are used solely for convenience and shall not be deemed to define or
limit the provisions of this Agreement.
Affiliation Agreement, Revised Marcia 2010
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13. NO WAIVER.
Any failure of a party to enforce that party's right under any provision of this Agreement shall not be
construed or act as a waiver of said party's subsequent right to enforce any of the provisions contained
herein.
14. GOVERNING LAW.
This Agreement shall be governed and construed in accordance with the laws of the State of Texas.
Venue for any disputes arising out of this Agreement shall be in Corpus Christi, Nueces County, Texas,
15. ASSIGNMENT; BINDING EFFECT.
Hospital may not assign or transfer any of its rights, duties or obligations under this Agreement, in whole
or in part, without the prior written consent of Entity. This Agreement shall inure to the benefit of, and be
binding upon, the parties hereto and their respective successors and permitted assigns.
16. NOTICES.
All notices hereunder by either party to the other shall be in writing, delivered personally, by
certified or registered mail, return receipt requested, or by overnight courier, and shall be deemed to
have been duly given when delivered personally or when deposited in the United States mail,
postage prepaid, addressed as follows:
If to Hospital Driscoll Children's Hospital
3533 South Alameda
Corpus Christi, TX 78411
Attn: Director of Center for Professional Development and Practice
If to Entity City of Corpus Christi
1261 Leopard Street
Corpus Christi, Texas 78401
Attn: City Attorney's Office
or to such other persons or places as either party may from time to time designate by written
notice to the other.
17. EXECUTION OF AGREEMENT,
This Agreement shall not become effective or in force until all of the below named parties have
fully executed this Agreement.
18. HIPAA REQUIREMENTS.
The parties agree to comply with the Health Insurance Portability and Accountability Act of 1996, as
codified at 42 U.S.C. Section 1320d ( "HIPAW), the Health Information Technology Economic and
Affiliation Agreement, Revised March 2010
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Clinical Health (HITECH) Act, and any current and future regulations promulgated there under,
including, without limitation, the federal privacy regulations contained in 45 C.F.R. Parts 160 and 164
( "Federal Privacy Regulations "), the federal security standards contained in 45 C.F.R. Part 142
( "Federal Security Regulations "), and the federal standards for electronic transactions contained in
45 C.F.R. Parts 160 and 162, all collectively referred to herein as "HIPAA Requirements ". The parties
agree not to use or further disclose any Protected Health Information (as defined in 45 C.F.R. Section
164.501) or Individually Identifiable Health Information (as defined in 42 U.S.C. Section 13204), other than
as permitted by the HIPAA Requirements and the terms of this Agreement. The parties agree to make their
internal practices, books and records relating to the use and disclosure of Protected Health Information
available to the Secretary of Health and Human Services to the extent required for determining compliance
with the Federal Privacy Regulations. In addition, the parties agree to comply with any state laws and
regulations that govern or pertain to the confidentiality, privacy, security of, and electronic and transaction code
sets pertaining to, information related to patients.
The Hospital shall direct its Program Participants to comply with the policies and procedures of Entity,
including those governing the use and disclosure of individually identifiable health information under federal
law, specifically 45 CFR parts 160 and 164. Solely for the purpose of defining the Program Participants' role in
relation to the use and disclosure of Entity's protected health information, the Program Participants are defined
as members of the Entity's workforce, as that term is defined by 45 CFR Section 160.103, when engaged in
activities pursuant to this Agreement. However, the Program Participants are not and shall not be considered to
be employees of Entity.
19. NO REQUIREMENT TO REFER.
Nothing in this Agreement requires or obligates Hospital to admit or cause the admittance of a patient to
Entity or to use Entity's services. None of the benefits granted pursuant to this Agreement is conditioned on
any requirement or expectation that the parties make referrals to, be in a position to make or influence referrals
to, or otherwise generate business for the other party. Neither party is restricted from referring any services to,
or otherwise generating any business for, any other entity of their choosing.
Affiliation Agreement, Revised March 2010
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IN WITNESS WHEREOF, the Parties have executed this Agreement to be effective as of the day and year
first above written,
HOSPITAL:
D RISCOLL CHILDREN'S HOSPITAL
By:
rIC �amon
Executive Vice President & CFO
ENTITY:
Cm
Date:
Affiliation Agreement, Revised March 2010
Date: _ f��I
Approved as to F•rm:
T. Trisha Dang Date
Assistant City Attorney for City Attorney
EXHIBIT A
STATEMENT OF RESPONSIBILITY AND WAIVER OF LIABILITY
For and in consideration of the benefit provided the undersigned in the form of experience in a clinical
setting ( "Program ") at the City of Corpus Christi ( "Entity "), I, the undersigned, binding my heirs, successors,
executors, administrators, and/or assigns do hereby release and agree to hold harmless the Entity, its
officers, agents, and employees from any and all actions, causes of actions, claims, demands or costs or
damages arising from or resulting from property damage, personal injuries or death sustained by me or my
property while participating in Entity's Mobile Intensive Care Unit, Fire Department vehicles, and on Entity's
property. Further, I agree to assume all risks in riding in Entity's Mobile Intensive Care Unit and Fire
Department vehicles while accompanying Entity's officers, agents, and employees or when on Entity's
property. I am fully aware that personal damage may be involved.
I make the following representations and acknowledgements upon which I intend the Entity to rely:
1. 1 realize and agree that while participating in the Program, I will not be an agent, servant, or
employee of the Entity and therefore will not be covered by Entity for any workman's
compensation, death or disability benefits.
2. 1 agree that any information I may gain, through participation in this Program will be kept
confidential.
3. 1 understand that my participation in the Program is a privilege subject to revocation at any time
by Entity, its officers, agents, or employees who is involved in the Program.
4. 1 have received and reviewed all orientation materials, Entity's policies and procedures and fully
understand the contents and actions required of each Program Participant.
Signature of Program Participant
Print Name:
Date
Parent /Legal Guardian if Program Participant under 18 Date
Print Name:
Relationship to Program Participant:
Affiliation Agreement, Revised March 2010
10
EXHIBIT B
PROTECTED HEALTH INFORMATION, CONFIDENTIALITY, AND SECURITY AGREEMENT
• Protected Health Information (PHI) includes patient information based on examination, test results, diagnoses,
response to treatment, observation, or conversation with the patient. This information is protected and the patient
has a right to the confidentiality of his or her patient care information whether this information is in written,
electronic, or verbal format. PHI is individually- identifiable information that includes, but is not limited to, patient's
name, account number, birth date, admission and discharge dates, photographs, and health plan beneficiary
number.
• Medical records, case histories, medical reports, images, raw test results, and medical dictations from healthcare
facilities are used for student learning activities. Although patient identification is removed, all healthcare
information must be protected and treated as confidential.
• Students enrolled in Hospital programs or courses and responsible faculty are given access to patient
information. Students are exposed to PHI during their clinical rotations in healthcare facilities.
• Students and responsible faculty may be issued computer identifications (IDs) and passwords to access PHI.
Initial each to accept the Policy:
Initial
Polic
1. It is the policy of the Hospital to keep PHI confidential and secure.
2. Any and all PHI, regardless of medium (paper, verbal, electronic, image or any other), is not to be disclosed
or discussed with anyone outside those supervising, sponsoring or directly related to the leamin activity.
3. Whether at the Hospital or at a clinical site, students are not to discuss PHI, in general or in detail, in public areas
under any circumstances, including hallways, cafeterias, elevators, or any other area where unauthorized people or those
who do not have a need -to -know may overhear.
4. Unauthorized removal of any part of original medical records is prohibited. Students and faculty may not release
or display copies of PHI. Case presentation material will be used in accordance with healthcare facility policies.
5. Students and faculty shall not access data on patients for whom they have no responsibilities or a "need -to-
know" the content of PHI concerning those patients.
6. A computer ID and password are assigned to individual students and faculty. Students and faculty are
responsible and accountable for all work done under the associated access.
7. Students and faculty agree to follow Entity's privacy policies.
8. Breach of patient confidentiality by disregarding the policies governing PHI is grounds for dismissal from the
Entity.
I agree to abide by the above policies and other policies at the clinical site. I further agree to keep PHI
confidential.
• 1 understand that failure to comply with these policies will result in disciplinary actions.
• 1 understand that Federal and State laws govern the confidentiality and security of PHI and that unauthorized
disclosure of PHI is a violation of law and may result in civil and criminal penalties.
Signature of Program Participant
Print Name:
Parent /Legal Guardian if Program Participant under 18
Print Name: Relationship:
Affiliation Agreement, Revised March 2010
Date
Date
11
ATTESTATION FORM 1 EXHIBIT "C"
[College Name Inserted Here]
Insert Date
Student #1
Student #2
Student #3
Student #4
Student #5
Student #6
Student #7
STUDENT NAME
DRIVERS LICENSE
15ate Verification (No Numbers please)
HEALTH INFORMATION
Date of Last PPD
(W ithin The Past Year
Hepatitis B Vaccine
Date of Confirmation OR
Date of Declined
Hepatitis B
MMR Immunizations
Date of Confirmation
Date of Varicella Titer Or
Positive Histo
Date of Influenza Vaccine
EDUCATION
Date of Entity Orientation
Completion
Date of Entity. Orientation
BACKGROUND INVESTIG
Social Security Number
Date of Verification
No SSN's lease
Date of Criminal Search
Up to 7 years, or Up to 5 searches
Date of HHS /OIG /GSA List of
Excluded Individuals
Date of Texas HHS List of
Excluded Individuals
Date of Violation Sexual Offender
& Predator Regist
As a designated representative of the Hospital named below, I attest that the above information is present in this student's file, and that the above named student has been determined to be
competent for the field of study and assigned area.
Hospital Representative Signature & Title: Date:
Affiliation Agreement, Revised & Approved Marcia 2010