HomeMy WebLinkAboutContract 50449 CLINICAL TRAINING AFFILIATION AGREEMENT CITY SERUM( b
CONTRACT NQ. J
This Clinical Training Affiliation Agreement ("Agreement") is entered into between
City of Fort Worth ("School") and North Texas Division, Inc., as disclosed agent for the following entities: North
Texas, MCA, LLC. — d/b/a Medical City Alliance, Columbia Medical Center of Denton Subsidiary, L.P. d/b/a
Medical City Denton, Green Oaks Hospital Subsidiary, L.P. d/b/a Medical City Green Oaks Hospital, Columbia
Medical Center of Las Colinas, Inc. d/b/a Medical City Las Colinas, Columbia Medical Center of Arlington
Subsidiary, L.P. d/b/a Medical City Arlington, Columbia Medical Center of Lewisville Subsidiary, L.P. d/b/a
Medical City Lewisville, Columbia Medical Center of McKinney Subsidiary, L.P. d/b/a Medical City McKinney,
Columbia Medical Center of Plano Subsidiary, L.P. d/b/a Medical City Plano, Columbia Hospital at Medical City
Dallas Subsidiary, L.P. d/b/a Medical City Dallas Hospital, Columbia North Hills Hospital Subsidiary, L.P. d/b/a
Medical City North Hills, and Columbia Plaza Medical Center of Fort Worth Subsidiary, L.P. d/b/a Medical City
Fort Worth (each a "Hospital') to be effective September 1,2017
School offers its enrolled students a degree in the field(s) checked below:
X Unlicensed Certification Program of Emergency Medical Sciences
Hospital operates a comprehensive acute-care medical-surgical facility. School desires to provide to its
students a clinical learning experience through the application of knowledge and skills in actual patient-
centered situations in a health care facility. Hospital has agreed to make its facility available to School for
these purposes.
In exchange for valuable consideration, the receipt and sufficiency of which is acknowledged, the
parties agree as follows:
1. RESPONSIBILITIES OF SCHOOL.
(a) Clinical Program. School will be responsible for the implementation and operation of the clinical
component of its program at Hospital ("Program"), which Program will be approved in advance by
Hospital. These responsibilities will include the following:
(i) Orientation of students to the clinical experience at Hospital;
(ii) Provision of classroom theory and practical instruction to students prior to their clinical
assignments at Hospital;
(iii) Preparation of student/patient assignments and rotation plans for each student and
2 3 coordination with Hospital;
t_ta Se (iv) Continuing oral and written communication with Hospital regarding student
performance and evaluation, absences and assignments of students, and other
9 �, pertinent information;
f1
Ngo (v) Supervision of students and their performance at Hospital;
9� (vi) Participation, with the students, in Hospital's Quality Assurance and related programs;
vii Performance of other duties as may from time to time be agreed to between School and
(vii) Y g
y Hospital;
(viii) Provide adequate documentation attesting to competency of each instructor.
All students, faculty, employees, agents and representatives of School participating in the Program
at Hospital ("Program Participants") will be accountable to the Hospital's Administrator.
ti
�Fqb) Student Statements. School will require each Program Particil ant to sign a Stateme it of
Responsibility, in the form attached as Exhibit A, and a Statem rAFIF d Security, in
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the form attached as Exhibit B. CITY��
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(c) Insurance. School will obtain and maintain, or will require each individual Program Participant to
obtain and maintain, 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 Hospital and covering
the acts and omissions of Program Participants. If this coverage is provided on a claims-made
basis, then the insurance will continue throughout the term of this Agreement and upon the
termination of this Agreement, or the expiration or cancellation of the insurance, School will
purchase, or will 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 (the tail coverage will be in amounts and type equivalent to the claims-made
coverage). School will further, at its expense, obtain and maintain workers' compensation
insurance and unemployment insurance for School employees assigned to Hospital. For all
insurance required by this Paragraph 1(c), School will require the insurance carrier notify Hospital
at least thirty (30) days in advance of any cancellation or modification of the insurance policy and
will provide to Hospital, upon request, certificates of insurance evidencing the above coverage and
renewals thereof. Notwithstanding the above, Hospital acknowledges that School is basically a
self-funded entity and as such, generally, it does not maintain a commercial liability insurance
policy; damages for which School would ultimately be found liable would be paid directly and
primarily by School and not by a commercial insurance company.
(d) Health of Program Participants. All Program Participants will pass a medical examination
acceptable to Hospital prior to their participation in the Program at Hospital at least once a year or
as otherwise required by Texas law. School and/or the Program Participant will 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 Hospital. Hospital
will not be financially, or otherwise, responsible for this medical care and treatment. Program
Participants will present the following health records on the first day of their educational
experience at Hospital (Program Participants will not be allowed to commence experiences until all
records):
(i) Tuberculin skin test within the past 12 months or documentation as a previous positive
reactor;
(ii) Proof of Rubella and Rubeola immunity by positive antibody titers or 2 doses of MMR;
(iii) Varicella immunity, by positive history of chickenpox or proof of Varicella immunization;
(iv) Proof of Hepatitis B immunization or declination of vaccine, if patient contact is
anticipated;
(v) Proof of Influenza vaccination during the Flu season, October 1 to March 31, (or dates
defined by CDC), or a signed Declination Form;
(vi) Evidence of a Negative 10-panel drug screen, performed upon admission to the School,
or, closer to the start time of clinical rotations; and
(vii) TDaP (Tetanus, Diphtheria and Pertussis) Booster(one dose as an adult) within 10 years.
(e) Dress Code; Breaks. School will require the students to dress in accordance with dress and
personal appearance standards approved by School. These standards will be in accordance with
Hospital's standards regarding same. All Program Participants will remain on the Hospital premises
for breaks, including meals. Program Participants will pay for their own meals at Hospital.
(f) Performance. All faculty provided by School will be duly licensed, certified or otherwise qualified
to participate in the Program at Hospital. School will have a specially designated staff for the
performance of the services specified herein. School and all Program Participants will perform its
and their duties and services hereunder in accordance with all relevant local, state, and federal
laws and will comply with the standards and guidelines of all applicable accrediting bodies and the
bylaws, rules and regulations of Hospital and any rules and regulations of School as may be in effect
from time to time. Neither School nor any Program Participant will interfere with or adversely
affect the operation of Hospital or the performance of services therein.
(g) Background Checks. School will timely conduct (or will timely have conducted) a background check
on every Program Participant at the Hospital. The background check will include, at a minimum,
the following:
(i) Social Security Number Verification;
(ii) Criminal Search (7 years or up to 5 criminal searches);
(iii) Employment Verification to include reason for separation and eligibility for re-
employment for each employer for 7 years (not required for students younger than 21
years of age),
If this blank is initialed, School has opted not to perform the employment verification required
in this subsection and instead agrees to indemnify Hospital and assume full liability for all
performance and behavior of School's students while they are participating in the Program;
(iv) Violent Sexual Offender and Predator Registry Search;
(v) HHS/OIG List of Excluded Individuals/Entities;
(vi) GSA List of Parties Excluded from Federal Programs;
(vii) Education verification (Highest Degree Received)
(viii) U.S. Treasury, Office of Foreign Assets Control (OFAC), List of Specially Designated
Nationals (SDN); and
(ix) Texas Medicaid Exclusions List
The background check for Program Participants who are licensed or certified caregivers will include
the above, and in addition, will include the following:
(i) Education verification (highest level);
(ii) Professional License Verification;
(iii) Certification & Designations Check;
(iv) Professional Disciplinary Action Search;
(v) Department of Motor Vehicle Driving History, based on responsibilities; and
(vi) Consumer Credit Report, based on responsibilities.
School will provide an Attestation of Satisfactory Background Investigation and Drug and Alcohol
Report in the form attached hereto as the Exhibit C prior to each student and staff/faculty
member's participation in the Program at the Hospital. If the background check discloses adverse
information, School will immediately remove Program Participant from the Program. One week
prior to any Program Participant reporting for work at Hospital, School will give Hospital either: (i) a
copy of the investigation results; or (ii) an attestation, compliant with Hospital's policies, that the
background check is completed and meets Hospital's requirements. School will allow Hospital to
randomly audit its student files according to HCA policy.
(h) Drug and Alcohol Testing. School represents that it will timely conduct (or will have timely
conducted) a drug and alcohol test on every Program Participant.
(i) To ensure the accuracy and fairness of the testing program, all collection and testing will be
conducted pursuant to guidelines established by the Medical Review Officers of the testing
facility and, if applicable, in accordance with Substance Abuse and Mental Health Services
Administration (SAMHSA) guidelines; a confirmatory test; the opportunity for a split sample;
review by an MRO, including the opportunity for employees or students who test positive to
provide a legitimate medical explanation, these as a physician's prescription,for the positive
result; and a documented chain of custody.
(ii) Substances tested prior to placement at Hospital must at a minimum include
amphetamines, barbiturates, benzodiazepines, opiates, marijuana, methadone, and
cocaine.
(iii) Program Participant will be required to undergo drug and alcohol testing upon reasonable
suspicion that the Program Participant has violated the policy, or after any"on-the-job"
accident, which involves injury requiring medical treatment or evaluation of the Program
Participant or another person, or property damage. Reasonable suspicion and reportable
accident testing will include amphetamines, barbiturates, benzodiazepines, carisoprodol,
opiates, fentanyl analogues, methadone meperidine, marijuana, and cocaine.
(i) School Status. School represents and warrants to Hospital that the School and its Program
Participants participating hereunder: (i) are not currently excluded, debarred, or otherwise
ineligible to participate in the Federal health care programs as 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, and (iii) are not under
investigation or otherwise aware of any circumstances which may result in the School or a Program
Participant being excluded from participation in the Federal health care programs. This will be an
ongoing representation and warranty during the term of this Agreement and the School will
immediately notify Hospital of any change in status of the representation and warranty set forth in
this section. Any breach of this Paragraph 1(h) will give Hospital the right to immediately terminate
this Agreement for cause.
2. RESPONSIBILITIES OF HOSPITAL.
(a) Hospital will accept the Program Participants assigned to the Program by School and reasonably
cooperate in the orientation of all Program Participants to Hospital. Hospital will provide
reasonable opportunities for these Program Participants, who will be supervised by School and
Hospital, to observe and assist in various-aspects of patient care to the extent permitted by
applicable law and without disruption of patient care or Hospital operations. Hospital will
coordinate School's rotation and assignment schedule with its own schedule and those of other
educational institutions. Hospital will at all times retain ultimate control of the Hospital and
responsibility for patient care.
(b) Upon the request of School, Hospital will assist School in the evaluation of each Program
Participant's performance in the Program. However, School will at all times remain solely
responsible for the evaluation and grading of Program Participants,
3. MUTUAL RESPONSIBILITIES. The parties will cooperate to fulfill the following mutual responsibilities:
(a) Students will be treated as trainees who have no expectation of receiving compensation or future
employment from the Hospital.
(b) Any courtesy appointments to faculty or staff by Hospital will be without entitlement of the
individual to compensation or benefits for the appointed party.
4. WITHDRAWAL OF PROGRAM PARTICIPANTS.
Hospital may request School to withdraw or dismiss a student or other Program Participant from the
Program at Hospital when his or her clinical performance is unsatisfactory to Hospital or his or her behavior, in
Hospital's discretion, is disruptive or detrimental to Hospital and/or its patients. If this happens, the Program
Participant's participation in the Program at Hospital will immediately cease. It is understood that only School
can dismiss the Program Participant from the Program.
5. INDEPENDENT CONTRACTOR; NO OTHER BENEFICIARIES.
The parties are independent contractors, and neither the School nor any of its agents, representatives,
Program Participants, or employees will be considered agents, representatives, or employees of Hospital. This
Agreement will not be construed as establishing a partnership or joint venture or similar relationship between
the parties. School will 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 will look to
Hospital for any salaries, insurance or other benefits. No Program Participant or other third person is entitled
to, and will not, receive any rights under this Agreement.
6. NON-DISCRIMINATION.
There will be no discrimination on the basis of race, national origin, religion, creed, sex, age, veteran
status, handicap,gender expression, gender identity, or transgender 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 handicap, the handicap 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 School's state law and without waiving any defenses, School will indemnify and
hold harmless Hospital and its officers, medical and nursing staff, representatives 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 School 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. Hospital will indemnify School against liabilities, claims, damages and
expenses, including reasonable attorneys' fees, incurred by School in defending or compromising actions
brought against School arising out of or related to the Hospital's performance of duties hereunder.
8. CONFIDENTIALITY.
School and its agents, Program Participants, faculty, representatives and employees agree to keep strictly
confidential and hold in trust all confidential information of Hospital and/or its patients and not disclose or
reveal any confidential information to any third party without the express prior written consent of Hospital,
except as required by law. School will 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 Hospital. Unauthorized disclosure of
confidential information or of the terms of this Agreement will be a material breach of this Agreement and will
provide Hospital with the option of pursuing remedies for breach, or, notwithstanding any other provision of
this Agreement, immediately terminating this Agreement upon written notice to School. Hospital
acknowledges that School is a governmental entity subject to Texas Government Code Section 552, known as
the Texas Public Information Act.
9. TERM;TERMINATION.
(a) The initial term of this Agreement will be 3 year(s), commencing on September 1, 2017 and
ending on August 31,2020.
(b) Either party may terminate this Agreement at any time without cause upon at least 30 days prior
written notice, provided that all Students currently enrolled in the Program at Hospital at the time
of notice of termination will be given the opportunity to complete their clinical Program at
Hospital, these completion not to exceed 6 months.
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 this subject matter. This Agreement may not be amended or modified except by mutual
written agreement. All continuing covenants, duties and obligations will 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, this Agreement
will remain in full force and effect in accordance with its terms disregarding this unenforceable or invalid
provision.
12. NO WAIVER.
Any failure of a party to enforce that party's right under any provision of this Agreement will not be
construed or act as a waiver of the party's subsequent right to enforce any of the provisions contained herein.
13. GOVERNING LAW;VENUE.
This Agreement will be governed and construed in accordance with the laws of the State of Texas and
venue shall be Tarrant County, Texas.
14. NOTICES.
All notices by either party will be in writing, delivered personally, by certified or registered mail, return
receipt requested, or by overnight courier, and will be deemed to have been duly given when delivered
personally or when deposited in the United States mail, postage prepaid, addressed as follows:
To: Medical City Healthcare
6565 N. MacArthur Blvd., Suite 350
Irving, TX 75039
Attention: Charlotte Morris, Workforce Development
To School: Leann D. Guzman Captain Sherri Hauch
Senior Assistant City Attorney EMS Program Manager
Chief—Real Estate&City Facilities Section FWFD EMS Office
City of Fort Worth 817-392-8753
200 Texas Street Sherri.Hauch@fortworthtexas.gov
Fort Worth,Texas 76102
817-392-8973
Leann.Guzman@fortworthtexas.gov
or to any other persons or places as either party may from time to time designate by written notice to the
other.
15. HIPAA Requirements.
To the extent applicable to this Agreement,the School agrees to comply with the Health Information
Technology for Economic and Clinical Health Act of 2009 (the "HITECH ACT"), the Administrative Simplification
provisions of the Health Insurance Portability and Accountability Act of 1996, as codified at 42 USC § 1320d
through d-8 ("HIPAA") and any current and future regulations promulgated under either the HITECH Act or
HIPAA including without limitation the federal privacy regulations contained in 45 C.F.R. Parts 160 and 164
(the "Federal Privacy Regulations"), the federal security standards contained in 45 C.F.R. Parts 160, 162 and
164 (the "Federal Security Regulations") and the federal standards for electronic Transactions Regulations"),
all as may be amended from time to time, and all collectively referred to herein as "HIPAA Requirements.".
The School further agrees not to use or disclose any Protected Health Information (as defined in 45 C.F.R. §
164.501) or Individually Identifiable Health Information (as defined in 42 USC§ 1320d), other than as
permitted by HIPAA Requirements and the terms of this Agreement. The School agrees to enter into any
further agreements as necessary to facilitate compliance with HIPAA Requirements.
The School will direct its Program Participants to comply with the policies and procedures of Hospital,
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 Hospital's protected health information, the Program Participants are
defined as members of the Hospital's workforce, as that term is defined by 45 CFR 160.103, when engaged in
activities pursuant to this Agreement. However, the Program Participants are not and will not be considered
to be employees of Hospital.
16. COMPLIANCE WITH HOSPITAL POLICIES AND PROCEDURES.
School and Program Participants will comply with Hospital Policies and Procedures to the extent these
Hospital Policies and Procedures do not conflict with the terms of this Agreement.
17. NO REQUIREMENT TO REFER.
Nothing in this Agreement requires or obligates School to admit or cause the admittance of a patient to
Hospital or to use Hospital'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.
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HOSPITAL: North Texas Division Inc. as Authorized Agent for:
North Texas, MCA, LLC.—d/b/a Medical City Alliance
Columbia Medical Center of Denton Subsidiary, L.P. d/b/a Medical City Denton
Green Oaks Hospital Subsidiary, L.P. d/b/a Medical City Green Oaks Hospital
Columbia Medical Center of Las Colinas, Inc. d/b/a Medical City Las Colinas
Columbia Medical Center of Arlington Subsidiary, L.P. d/b/a Medical City Arlington
Columbia Medical Center of Lewisville Subsidiary, L.P. d/b/a Medical City Lewisville
Columbia Medical Center of McKinney Subsidiary, L.P. d/b/a Medical City McKinney
Columbia Medical Center of Plano Subsidiary, L.P. d/b/a Medical City Plano
Columbia Hospital at Medical City Dallas Subsidiary, L.P. d/b/a Medical City Dallas Hospital
Columbia North Hills Hospital Subsidiary, L.P. d/b/a Medical City North Hills
and Columbia Plaza Medical Center of Fort Worth Subsidiary, L.P. d/b/a Medical City Fort Worth
FP2---
Erol R. Akdamar, FA HE
President, HCA North Texas Division, Inc.
Medical City Healthcare
Date:
OFFICIAL RECORD
CITY SECRETARY
FT.WORTH,TX
EXHIBIT A
STATEMENT OF RESPONSIBILITY
In exchange for the opportunity to gain experience in evaluation and treatment of patients at
(Hospital Name) ("Hospital"), I, and on behalf of my heirs,
successors and/or assigns, agree to be solely responsible for any injury or loss I sustain while participating in
the educational program at Hospital, unless the injury or loss arises solely out of Hospital's gross negligence.
Program Participant
Date:
EXHIBIT B
Confidentiality and Security Agreement
I understand that the Hospital where I will be learning manages health information as part of its mission to treat
patients. Further, I understand that the Hospital has a legal and ethical responsibility to safeguard the privacy of
all patients and to protect the confidentiality of their patients' health information. Additionally, the Hospital
must assure the confidentiality of its human resources,payroll, fiscal, research, internal reporting, strategic
planning information, or any information that contains Social Security numbers, health insurance claim
numbers, passwords,PINs, encryption keys, credit card or other financial account numbers (collectively, with
patient identifiable health information, "Confidential Information").
In the course of my assignment at Hospital, I understand that I may come into the possession of this type
of Confidential Information. I will access and use this information only when it is necessary to perform my
duties in accordance with the Hospital's Privacy and Security Policies,which are available on the Hospital
intranet(on the Security Page) and the Internet(under Ethics & Compliance). I further understand that I must
sign and comply with this Agreement in order to obtain authorization for access to Confidential Information or
Hospital systems.
General Rules:
1. I will act in the best interest of the Hospital and in accordance with its Code of Conduct at all times
during my relationship with the Hospital.
2. I understand that I should have no expectation of privacy when using Hospital information systems.
The Hospital may log, access, review, and otherwise utilize information stored on or passing
through its systems, including email, in order to manage systems and enforce security.
3. I understand that violation of this Agreement may result in disciplinary action, up to and including
termination of employment, suspension, and loss of privileges, and/or termination of authorization
to work within the Hospital, in accordance with the Hospital's policies.
Protecting Confidential Information:
1. I understand that any Confidential Information, 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 learning activity.
2. I will not disclose or discuss any Confidential Information with others, including friends or family,
who do not have a need to know it. I will not take media or documents containing Confidential
Information home with me unless specifically authorized to do so as part of my job. Case
presentation material will be used in accordance with Facility policies.
3. I will not publish or disclose any Confidential Information to others using personal email, or to any
Internet sites, or through Internet blogs or sites such as Facebook or Twitter. I will only use these
communication methods when explicitly authorized to do so in support of Hospital business and
within the permitted uses of Confidential Information as governed by regulations such as HIPAA.
4. I will not in any way divulge, copy, release, sell, loan, alter, or destroy any Confidential Information
except as properly authorized. I will only reuse or destroy media in accordance with Hospital
Information Security Standards and Hospital record retention policy.
5. In the course of learning, I may need to orally communicate health information to or about patients.
While I understand that my first priority is patient safety, I will take reasonable safeguards to
protect conversations from unauthorized listeners. Whether at the School or at the Facility, these
safeguards include, but are not limited to: lowering my voice or using private rooms or areas (not
hallways, cafeterias or elevators)where available.
6. I will not make any unauthorized transmissions, inquiries, modifications, or purgings of
Confidential Information. I will not access data on patients for whom I have no responsibilities or a
need-to-know the content of the PHI concerning those patients.
7. I will not transmit Confidential Information outside the Hospital network unless I am specifically
authorized to do so as part of my job responsibilities. If I do transmit Confidential Information
outside of the Hospital using email or other electronic communication methods, I will ensure that
the Information is encrypted according to Hospital Information Security Standards.
Following Appropriate Access:
1. I will only access or use systems or devices I am officially authorized to access, and will not
demonstrate the operation or function of systems or devices to unauthorized individuals.
2. I will only access software systems to review patient records or Hospital information when I have a
business need to know, as well as any necessary consent. By accessing a patient's record or
Hospital information, I am affirmatively representing to the Hospital at the time of each access that
I have the requisite business need to know and appropriate consent, and the Hospital may rely on
that representation in granting these access to me.
Using Portable Devices and Removable Media:
1. I will not copy or store Confidential Information on removable media or portable devices such as
laptops,personal digital assistants (PDAs), cell phones, CDs,thumb drives, external hard drives,
etc., unless specifically required to do so by my job. If I do copy or store Confidential Information
on removable media, I will encrypt the information while it is on the media according to Hospital
Information Security Standards
2. I understand that any mobile device (Smart phone,PDA, etc.)that synchronizes Hospital data (e.g.,
Hospital email) may contain Confidential Information and as a result, must be protected. Because
of this, I understand and agree that the Hospital has the right to:
a. Require the use of only encryption capable devices.
b. Prohibit data synchronization to devices that are not encryption capable or do not support
the required security controls.
c. Implement encryption and apply other necessary security controls (such as an access PIN
and automatic locking) on any mobile device that synchronizes Hospital data regardless of it
being a Hospital or personally owned device.
d. Remotely "wipe" any synchronized device that: has been lost, stolen or belongs to a
terminated employee or affiliated partner.
e. Restrict access to any mobile application that poses a security risk to the Hospital network.
Doing My Part—Personal Security:
1. I understand that I will be assigned a unique identifier(e.g., 3-4 User ID)to track my access and use
of Confidential Information and that the identifier is associated with my personal data provided as
part of the initial and/or periodic credentialing and/or employment verification processes.
2. I will:
a. Use only my officially assigned User-ID and password (and/or token (e.g., SecurID card)).
b. Use only approved licensed software.
c. Use a device with virus protection software.
3. I will never:
a. Disclose passwords,PINS, or access codes.
b. Use tools or techniques to break/exploit security measures.
c. Connect unauthorized systems or devices to the Hospital network.
4. I will practice good workstation security measures these as locking up diskettes when not in use,
using screen savers with activated passwords,positioning screens away from public view.
5. I will immediately notify my proctor or instructor, Facility Information Security Official (FISO),
Director of Information Security Operations (DISO), or Facility or Corporate Client Support
Services (CSS) help desk if:
a. my password has been seen, disclosed, or otherwise compromised;
b. media with Confidential Information stored on it has been lost or stolen;
c. I suspect a virus infection on any system;
d. I am aware of any activity that violates this agreement,privacy and security policies; or
e. I am aware of any other incident that could possibly have any adverse impact on
Confidential Information or Hospital systems.
Upon departure:
1. I agree that my obligations under this Agreement will continue after my relationship ceases with the
Hospital.
2. Upon departure, I will immediately return any documents or media containing Confidential
Information to the Hospital.
3. I understand that I have no right to any ownership interest in any Confidential Information accessed
or created by me during and in the scope of my relationship with the Hospital.
By signing this document, I acknowledge that I have read this Agreement and I agree to comply with all the
terms and conditions stated above.
Student's Signature Hospital Name and Date
COID
Student's Printed Name Business Entity
Name
EXHIBIT C
Attestation Form
School Letter Head
Date
Facility Name/Dept/Address
This letter is to verify that each faculty and students on the attached sheet from (name of school, course number and
name, rotation date) have met, and has evidence on file,the background investigation Level I requirements as outlined
in HCA's Human Resources Policy HR.OP.002. Level I requirements are:
• Social Security Number verification
• Criminal Search (7 years or up to 5 criminal searches)
• Employment Verification to include reason for separation and eligibility for reemployment for each
employer for 7 years (not required for students younger than 21)
(Opt out clause available per Affiliation Agreement.)
• Violent Sexual Offender and Predator Registry Search
• HHS/OIG List of Excluded Individuals/Entities
• GSA List of parties Excluded from Federal Programs
• US Treasury, Office of Foreign Asset Control (OFAC), List of Specially Designated Nations (SDN)
• Texas Medicaid Exclusions List
In addition I certifythat all faculty and students have met, and have evidence on file,the following requirement for
participation in the clinical education program, rip or to, and not expiring anytime during the clinical rotation:
• Current BLS for Healthcare Provider
• Standard Hospital Orientation Packet review,with passing score of 100% on post-test
• Required immunizations completed
o TB Skin Test and/or CXR (Annual TB testing.)
o Hepatitis B Series
o Seasonal Flu Immunization (September—March)
o MMR (Measles, Mumps and Rubella) documentation of 2 doses ortiter
o Varicella vaccination or titer or proof of illness by a physician
o TDaP (Tetanus, Diphtheria and Pertussis) Booster(one dose as an adult)within 10 years.
• Liability Insurance
• Drug Screening
• Review and agree to Confidentiality statement (in student orientation packet)
• If applicable, current RN license—faculty only
• Clinical competency in area or unit of clinical rotation—faculty only
Refer to HCA North Texas Clinical Training Affiliation Agreement
Sincerely,