Section 2912
Attachment 2
REQUEST FOR AFFILIATION OR TRAINING AGREEMENT
(For training in UCDHS facilities of students of a non-UCD non-physician training program)
Date:
Please complete the following questionnaire and forward it to the Health System Contracts office. Should you
have any questions or require additional information, please feel free to call the Health System Contracts office
at (916) 734-3820.
1.
UCDHS department requesting agreement:
Departmental contact:
Title:
Phone number:
2.
Please describe how this affiliation will benefit the University or relate to the University's missions of
teaching, research and public service:
3.
(a)
4.
5.
(b)
(c)
What is the legal name of the institution which will send its students to UCDHS for clinical
experience?
Address:
Contact Person:
Phone Number:
Is this institution for-profit or not-for-profit?
Is this institution accredited?
If yes, by what accreditation body?
(a)
What degree/license/certification are the students working toward?
(b)
(c)
What type of students will be assigned to UCDHS (i.e., nursing students, physical therapy
students, ultrasound technician students, etc.)?
Will the students assigned to UCDHS be undergraduate or graduate students?
(d)
What type of education and experience will they have had?
(a)
How many students will be assigned to UCDHS per week/ month/quarter/semester, etc.
(whichever is applicable)?
Approximately how many hours per week/month/quarter/ semester will each student be assigned
to UCDHS?
What is the duration of any one student's assignment?
(b)
(c)
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6.
Which UCDHS department(s) will the students be assigned to?
7.
Period of Agreement: From
8.
Please provide a brief description of what the students will do at UCDHS. (Be sure to indicate whether
hands-on patient care will be performed by students.)
9.
(a)
Who will provide direct supervision of these students? (i.e., UCDHS clinical nurses, UCDHS
physical therapists, on-site instructors from the other institution, etc.):
(b)
Who will coordinate and supervise the training program?
(c)
Approximately how many hours per week will UCDHS staff be required to devote to the
orientation, coordination, instruction, supervision, and evaluation of these students?
to
10.
What type of malpractice risk is involved with these students?
11.
(a)
(b)
(c)
12.
Will any student:
(a)
drive or ride in an ambulance?
(b)
drive on behalf of UCDHS?
(c)
transport patients by automobile/van, etc?
13.
Will students need to know Universal Precautions?
14.
Will students be evaluated?
(a)
How frequently?
(b)
By whom?
Will the institution reimburse UCDHS for training its students?
If so, how much?
Does the department have a policy on training fees that has been approved by [the Associate
Director to whom the department reports or the Executive Director of Human Resources for
UCDHS]? If so, please attach a copy of the policy.
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15.
Are there any particular provisions you would like included in the agreement? If so, please list:
16.
If the institution has provided you with a copy of their agreement form, please attach.
17.
The above affiliation has been approved by:
Department Manager: Name:
Signature:
Date:
Assistant Director: Name:
Signature:
Date:
Associate Director: Name:
Signature:
Date:
PLEASE OBTAIN ALL THREE APPROVALS BEFORE FORWARDING FORM TO TRAINING
LIAISON