Instructions for Placement Agreement for Clinical Practicum
Please insert the applicable information in designated areas as follows:
Date Line - 1st Tab:
Insert the day
Date Line - 2nd Tab:
Insert the month
Date Line - 3rd Tab:
Insert the year
Name of other party - 4th Tab:
Insert full legal name of the Field Placement Site
Preamble - 1st Tab:
Identify discipline (i.e. Pharmacy)
Section 1 - 1st Tab:
Insert month and day when the Agreement will begin
Section 1 - 2nd Tab:
Insert year when the Agreement will begin
Section 1 - 3rd Tab:
Insert month and day when the Agreement will end
Section 1 - 4th Tab:
Insert year when the Agreement will end
Section 2 (a):
Insert the position of the liaison for the Placement Site
Section 2 (b):
Insert the position of the liaison for the University
Section 17:
1st Tab:
Insert the name of the Field Placement Site
2nd Tab:
Insert the street address of the Field Placement Site
3rd Tab:
Insert the City, Province and Postal Code (in that order) of the
Field Placement Site
4th Tab:
Insert the name of the Department within the University for
notice purposes
5th Tab:
Insert the building/ address for the Department within the
University for notice purposes
6th Tab:
Insert the City, Province and Postal Code (in that order) for the
Department within the University for notice purposes
Signature Line:
1st Tab:
Insert the title of University signing authority (ie. Dean, Faculty
of Pharmacy)
2nd Tab:
Insert full legal name of Field Placement Site (should be the same
as at the outset of Agreement)
3rd Tab:
Insert title of Field Placement Site’s signing authority (if known)
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4th Tab:
Insert title of Field Placement Site’s second signing authority (if
known and if applicable)
Routing –please also see: http://umanitoba.ca/admin/vp_admin/legal/media/signing_policy.pdf
1.
forward the completed Agreement to the appropriate Dean or Director for signature, ensuring that a
sufficient number of copies of the Agreement are signed so that each party who will be signing the
Agreement may keep an original copy.
2.
arrange for the other party to sign the Agreement.
3.
Once all signatures are obtained, provide one original copy to each party. The University’s copy must
be forwarded to the Office of Legal Counsel for filing in the University’s central contracts vault. A
photocopy of the Agreement should be kept for your records.
THIS AGREEMENT made in duplicate as of the
day of
, 20
.
BETWEEN:
THE UNIVERSITY OF MANITOBA
(the “University”)
- and -
(the “Field Placement Site”)
WHEREAS it is in the interests of the University and the Field Placement Site that the development
of
in Manitoba be furthered through the educational preparation of the students of the
University by way of clinical experience at the Field Placement Site.
NOW THEREFORE this Agreement witnesseth that in consideration of the mutual covenants herein
contained the parties hereto agree that:
1.
This Agreement shall commence on
, 20
and end on
, 20
.
2.
Liaison between the University and the Field Placement Site shall be by and through the
following persons:
(a)
on behalf of the Field Placement Site, the
, or such other individual as the Field
Placement Site may delegate from time to time; and,
(b)
on behalf of the University, the
delegate from time to time;
, or such other individual as the University may
(collectively referred to as the “Liaison”). The Liaison will consult by telephone on a regular
and planned basis.
3.
The University shall notify the Field Placement Site that the University has approved each
clinical practicum proposal developed by a University student in consultation with an
academic advisor and the Field Placement Site (the “Clinical Practicum”).
Changes may not be made to any University approved Clinical Practicum without the
University’s prior approval.
4.
The Field Placement Site will plan and conduct a period of orientation to the Field Placement
Site for the students prior to the commencement of each Clinical Practicum. It is
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contemplated that the orientation period will include the presentation of selected current
policies, regulations and procedures of the Field Placement Site.
5.
The University acknowledges the importance of confidentiality of personal health
information in accordance with The Personal Health Information Act (Manitoba)(the “Act”)
and patient privacy laws. In compliance with its obligations under the Act, the Field
Placement Site will, as part of its orientation program, distribute and explain to the students,
a confidentiality pledge in such form and content as may be appropriate, in accordance with
the Act. The Field Placement Site shall maintain the confidentiality pledges within its record
as evidence of its compliance with the Act.
The University shall not be liable in any manner for a failure or omission by the Field
Placement Site to comply with its obligations under the Act in connection with the form,
content or execution of the confidentiality pledges, or any other related or other matter under
the Act.
6.
The Field Placement Site will provide for the undergraduate students of the University,
without charge to the University, such facilities at the Field Placement Site as are reasonable
and appropriate, lockers or change rooms, access to cafeteria and/or eating room, class and/or
conference rooms, use of a library and parking space (to be provided free only if no parking
charge is made to other persons).
7.
The Field Placement Site shall be responsible for:
8.
(a)
instruction and supervision of student(s) during each Clinical Practicum;
(b)
such evaluation and reports as required by the University.
As students under The Workers Compensation Act (Manitoba) (the “Workers Compensation
Act”) students engaged in the Clinical Practicum are covered for injuries in accordance with
and subject to the provisions of the Workers Compensation Act. In the event of an injury
during the Clinical Practicum, the Field Placement Site Liaison should promptly contact the
University Liaison to ensure that a report and claim can be made to the Workers
Compensation Board.
Where the location of the Field Placement Site is outside of the Province of Manitoba, and
students engaged in the Clinical Practicum are not resident in Manitoba, the University
makes no representation as to workers compensation coverage in place.
9.
The University shall indemnify and save harmless the Field Placement Site and its officers,
servants and agents from every action, suit or claim in respect of any injury, loss or damage
resulting from the negligent acts or omissions by the University, its officers or servants,
when acting within the scope of their employment or by the undergraduate students when
acting within the scope of the Clinical Practicum, except to the extent that injury, loss or
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damage is caused by the act or omission of the Field Placement Site, or any of its officers,
servants or agents.
10.
The Field Placement Site shall indemnify and save harmless the University and its officers,
servants and agents from every action, suit or claim in respect of any injury, loss or damage
resulting from the negligent acts or omissions by the Field Placement Site, its officers or
servants, when acting within the scope of their employment, except to the extent that injury,
loss or damage is caused by the act or omission of the University, or any of its officers,
servants or agents, or by students acting within the scope of the Clinical Practicum.
11.
This Agreement may be terminated any time by either party giving four (4) clear months
written notice to the other party, provided, however, that any scheduled Clinical Practicum
will not be terminated prior to completion by the student(s) of the said Clinical Practicum
(except where just cause exists in relation to any individual student’s conduct during the
corresponding Clinical Practicum).
12.
The parties may amend any provision of this Agreement at any time upon mutually so
agreeing in writing.
13.
The Field Placement Site shall, in keeping with its responsibilities to its clients, have the
right to intervene in those instances where a student may be functioning in a manner
considered to be of potential risk to the well-being of the client or contrary to the regulations,
rules, policies or procedures of the Field Placement Site. In such event, the University shall
withdraw a student from a Clinical Practicum if requested by the Field Placement Site.
14.
The Field Placement Site shall not, without obtaining the prior written consent of the
University, assign or transfer this Agreement or any interest herein.
15.
Sections 5 (if applicable), 9 and 10 shall survive termination of this Agreement.
16.
This Agreement shall be construed in accordance with the laws of Manitoba as applied to
transactions taking place entirely within Manitoba between Manitoba residents.
17.
All notices to be given by either party to the other under this Agreement shall be delivered or
mailed by registered or certified post, postage prepaid, addressed to such other party
respectively as follows:
If to the Field Placement Site:
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If to the University:
18.
This Agreement may be executed in any number of counterparts and by different parties in
separate counterparts, each of which when so executed shall be deemed to be an original and
all of which taken together shall constitute one and the same agreement. Delivery by
facsimile or by electronic transmission in portable document format (PDF) of an executed
counterpart of this Agreement is as effective as delivery of an originally executed counterpart
of this Agreement.
IN WITNESS WHEREOF the parties have hereto executed this Agreement as of the day and year
first above written.
THE UNIVERSITY OF MANITOBA
Per:
Title:
Per:
Title:
Per:
Title:
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