UNIVERSITY OF NEBRASKA MEDICAL CENTER
COLLEGE OF ???
VOLUNTEER CLINICAL FACULTY (Unpaid Special Appointment)
AGREEMENT AND RELEASE FORM
This Agreement is made and entered into this day of, 2010, by and between the BOARD OF REGENTS OF THE UNIVERSITY OF NEBRASKA, a
public body corporate, for and on behalf of the University of Nebraska Medical Center, hereinafter called "UNMC" and,
hereinafter called
"Volunteer".
1.
Volunteer agrees that s/he is volunteering solely for personal, civil, charitable or humanitarian purposes without promise or expectation of
compensation, benefits or future employment from the UNMC beyond any specified reimbursement agreements. Volunteer understands
that his/her relationship with the UNMC carries with it no promise of continuation and can be terminated in accordance with the BOARD
OF REGENTS OF THE UNIVERSITY OF NEBRASKA Bylaws (Bylaws) and the BOARD OF REGENTS OF THE UNIVERSITY OF
NEBRASKA Policies (Policies).
2.
The professional staff appointment status of Volunteer shall be a Special Appointment at the rank of Adjunct enter rank (clinician) in the
Department of
The term of Volunteer’s Special Appointment shall begin on
and is subject to Section 4.4.1 of the Bylaws.
3.
Volunteer will perform services under the direction and control of UNMC faculty.
4.
Volunteer agrees to perform the teaching, service, and research duties and responsibilities set forth in the written statement attached to
this Agreement as Appendix “A” and incorporated herein by reference. Volunteer and UNMC agree that Appendix A shall be periodically
reviewed and revised as appropriate in accordance with the Bylaws.
5.
Volunteer agrees to follow the directions of UNMC faculty and to abide by Bylaws and the Policies while carrying out these volunteer
services. Volunteer understands that s/he may be subject to criminal background checks or other prescreening checks, if applicable.
Volunteer acknowledges that s/he has been informed of the aforementioned Bylaws and Policies. Bylaws can be found at
www.nebraska.edu/board/board_bylaws.shtml. Policies can be found at www.nebraska.edu/board/board_policies.shtml).
6.
Volunteer acknowledges that s/he is not an employee of the UNMC, and is not entitled to receive salary, benefits or other compensation.
Volunteer understands that s/he does not qualify for worker’s compensation benefits, and is expected to carry personal medical insurance
to cover medical expenses for any injury s/he may incur while performing services voluntarily for the UNMC.
7.
So long as Volunteer is acting within the course and scope of his/her volunteer assignment, UNMC, through its self-insurance program, will
provide a legal defense if someone outside the UNMC brings a claim against Volunteer for acts performed by Volunteer in good faith and
as part of his/her UNMC responsibilities.
8.
As a condition of initial and continued volunteer status, Volunteer will immediately apply for, obtain and maintain, at all times during the
term of this Agreement, a full and unrestricted license to practice medicine in the state of Nebraska. Volunteer’s inability to obtain or
maintain such license may subject Volunteer to immediate termination of this Volunteer Agreement.
9.
As a condition of initial and continued volunteer status, Volunteer will immediately apply for obtain and maintain an unrestricted Drug
Enforcement Administration license to prescribe controlled substances at all times during volunteer status with UNMC. Volunteer’s inability
to obtain or maintain such license may subject Volunteer to immediate termination of this Volunteer Agreement.
10. If Volunteer is not a citizen or permanent resident of the United States, Volunteer certifies that s/he has appropriate visa status that
authorizes Volunteer to be present in the United States and allows Volunteer to participate in this volunteer experience.
11. As a condition of initial and continued volunteer status, Volunteer must immediately apply for, receive and maintain Medical
Staff Privileges at The Nebraska Medical Center and/or UNMC Physicians. Medical staff inpatient privileges will be in
accordance with the Bylaws of UNMC Physicians and the Bylaws of the Medical Staff of The Nebraska Medical Center
and/or clinic privileges in accordance with the Bylaws of UNMC Physicians. Delays in completion and/or inability to obtain
and maintain medical staff privileges as provided herein may subject Volunteer to immediate termination of this Volunteer
Agreement.
12. Professional liability insurance is as described in Section 13 of Volunteer’s separate UNMC Physicians Volunteer Agreement.
13. This Agreement shall be construed and enforced in accordance with, and is subject to the Bylaws and Policies as well as the laws of the
State of Nebraska.
Volunteer Faculty Agreement
and Release Form (7-10)
Faculty Initials __________
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14. The parties agree that this is the entire Agreement between them and that no Agreement, either oral or written, exists outside this
Agreement regarding the volunteer services described in this Agreement.
VOLUNTEER RELEASE
Volunteer releases the BOARD OF REGENTS OF THE UNIVERSITY OF NEBRASKA, its officers, employees, agents, representatives and assigns,
from any responsibility or liability for personal injury, including death, and the damage to or loss of property, that Volunteer may incur due to the
negligence of the BOARD OF REGENTS OF THE UNIVERSITY OF NEBRASKA, its officers, employees, agents, representatives and assigns or
others due to accidental occurrences while visiting the UNMC or otherwise engaging in activities contemplated by this Agreement.
IN WITNESS WHEREOF, the parties have executed this Agreement on the dates indicated below.
ACCEPTED:
By: ______________________________________ this _______ day of _____________, 20____.
Faculty Member
APPROVED:
By: _____________________________________ _____________
Date
Department Chair
By: _____________________________________ _____________
Dean, College of ???
Date
THE BOARD OF REGENTS OF THE
UNIVERSITY OF NEBRASKA
By: ________________________________________ ____________
Vice Chancellor for Academic Affairs, UNMC
Date
Attachment: Appendix “A”
Volunteer Faculty Agreement
and Release Form (7-10)
Faculty Initials __________
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