Agreement for Clinical Placement of
Clinical Pastoral Education Student
This Agreement for Clinical Placement of Clinical Pastoral Education students (the “Agreement”) is
entered into this ___ day of
,
by and between (CPE Center)
(“Accredited Center”) and (Placement Site) (“Placement Site”).
This Agreement will govern the Clinical Pastoral Education (CPE) Student Units offered by the Spiritual
Care Department of (CPE Center) on the (Placement Site) campus. (CPE Center) is an institution
sponsored center accredited by the Association for Clinical Pastoral Education, Inc. to offer Level I and
Level II CPE.
The following agreement outlines the obligations of the Spiritual Care Department at ACCREDITED
CENTER and PLACEMENT SITE for the clinical placement of CPE students as part of the unit of CPE
in which a student trains. The CPE faculty of ACCREDITED CENTER will provide all of the resources
necessary to insure that CPE students are able to participate in the CPE program that meets The
Association of Clinical Pastoral Education (ACPE) accreditation requirements as delineated in the 2010
Standards of the ACPE, section 303 entitled “An ACPE Center shall have educational resources that
provide:
303.1
a faculty of sufficient size to fulfill program goals and comprised of persons authorized
by ACPE. A center’s faculty must include at least one supervisor certified by ACPE as
Associate Supervisor or ACPE Supervisor.
 An Associate CPE Supervisor or CPE Supervisor may be the supervisor for no
more than 13 full-time equivalent (FTE) students in CPE (Level I/ Level II).
 A Supervisory Candidate may be the supervisor for no more than 6 CPE (Level
I/ Level II) students. (FTE does not apply to students of Supervisory
Candidates).
 In supervisory education, a center’s faculty should include at least one ACPE
Supervisor for every 4 FTE Supervisory Education Students or Supervisory
Candidates.
303.2
a faculty development plan.
303.3
interdisciplinary consultation and teaching within the program(s) provided by adjunct
faculty and/or guest lecturers.
303.4
individual and group supervision by a person authorized by ACPE.
303.5
a peer group of at least three CPE (Level I/II) students engaged in small group process
and committed to fulfilling the requirements of the educational program.
303.6
access to library and educational facilities adequate to meet the ACPE Standards.
303.7
access to current ACPE standards and commissions’ manuals, the ACPE Policy for
Complaints Alleging Violation of ACPE Education Standards, and the ACPE Policy for
Complaints Against the Accreditation Commission (See Appendix 10 ACPE
Accreditation Manual.
303.8
student support services including, but not limited to, orientation, a process for
educational guidance and recommendations for counseling resources, resume preparation
and employment search.”
PLACEMENT SITE agrees to allow CPE students to utilize their experiences as chaplains in order to
fulfill the minimum ACPE Standards requirements for clinical hours. Clinical and on-call hours will be
negotiated between the Director of Spiritual Care, CPE student, and CPE Supervisor. The minimum
ACPE Standards requirement for 100 curriculum hours will be fulfilled at ACCREDITED CENTER. The
combined time shall be no less than 400 hours.
As part of this training agreement, PLACEMENT SITE understands that CPE students will prepare
reflective summaries and reports on ministry encounters. It is further understood that all written reports
and verbal exchanges will not identify any individuals by name, and that these experiences will be used
for training purpose only and within strict bounds of professional confidentiality. CPE students must
agree to appropriately safeguard the protected health information of patients, in accordance with
applicable provisions of the Health Insurance Portability and Accountability Act of 1996, as amended,
and its attendant regulations (collectively, “HIPAA”) and may use and disclose protected health
information solely for the education purposes contemplated by this Agreement.
With respect to information obtained or received from ACCREDITED CENTER or PLACEMENT SITE,
the CPE students shall: (i) not use or further disclose the information other than as permitted or required
by this Agreement or as required by law; (ii) use appropriate safeguards to prevent use or disclosure of
the information other than as provided for by this Agreement; and (iii) report to the Spiritual Care
Department of ACCREDITED CENTER any use or disclosure of the information not provided for by
this Agreement of which the CPE student becomes aware. Each CPE student shall be required to sign the
confidentiality form attached hereto as Exhibit A.
PLACEMENT SITE grants the ACCREDITED CPE CENTER CPE faculty the privilege to make site
visits to PLACEMENT SITE during defined units of training. The purpose of these visits will be to
allow the CPE supervisor to become familiar with the clinical context in which the student is functioning.
ACCREDITED CPE CENTER CPE Responsibilities
 The interview committee will consist of at least three persons, one being a member of the CPE
faculty.
 The primary ACPE Supervisor at ACCREDITED CPE CENTER will serve as the primary pastoral
educator for the student and will be responsible for all CPE activities.
 ACCREDITED CPE CENTER may offer summer (full-time) and extended (part-time) training.
 CPE units will offer relational learning environments that foster growth in pastoral formation,
reflection and competence; such environments involve mutual trust, openness, challenge, conflict and
confrontation.
 CPE students will have access to the ACCREDITED CPE CENTER libraries, as detailed in the
student handbook.
 CPE students will have space and computer access provided at the ACCREDITED CPE CENTER
student area.
 CPE students will have access to the hospital network.
PLACEMENT SITE Clinical Responsibilities
 The Director of Pastoral Care at PLACEMENT SITE will oversee the chaplain student’s clinical
practice of ministry. This will include clinical orientation to PLACEMENT SITE, weekly review of
clinical ministry, and feedback to the CPE supervisor for evaluation of student performance.
 Clinical placement will provide access to a population that offers significant opportunity for
ministry, opportunities for interdisciplinary/professional interchange, and an environment that
encourages human growth and dignity. The student will have access to patient files and information
as part of the healthcare team.
 CPE students will have space and computer access provided at PLACEMENT SITE.
This placement agreement will remain in effect until one of the parties dissolves it. This dissolution may
occur at the end of any CPE residency year with sufficient notice to all other parties signing this
agreement.
______________________________________________
Administrator
Placement Site
__________________
Date
______________________________________________
Director of Pastoral Care
Placement Site
__________________
Date
______________________________________________
Administrator
Accredited CPE Center
__________________
Date
______________________________________________
Director of Spiritual Care
Accredited CPE Center
__________________
Date
EXHIBIT A
STUDENT CONFIDENTIALITY AGREEMENT
This Student Confidentiality Agreement is effective the ________day of _______________, _____
between_________________________________ ("Facility") and ______________________________
("Student"), a CPE student, to participate in Clinical Rotations at Facility. Student agrees as follows:
Confidentiality: Student acknowledges that as a result of the Clinical Rotations, he/she may have access
to confidential information, including the identities of patients. To the extent allowed by law, Student
shall hold confidential all patient and Facility information obtained as a participant in these activities and
not to disclose any personal, medical, or related information to third parties, family members, other
students, or teachers. Student is committed to protect and safeguard from any oral and written disclosure
all confidential information with which he/she may come in contact. Student shall not be permitted to
copy and/or have access to patient medical records except as permitted by Facility. Except as permitted
or required by this Agreement or by law, Student will not use or disclose patient information in a manner
that would violate the applicable requirements of the Privacy and Security Standards contained in the
Health Insurance Portability and Accountability Act of 1996 and its regulations ("HIPAA"), which are
incorporated herein by reference. Student expressly agrees to comply with the applicable provisions of
HIPAA in all respects, including the implementation of all necessary safeguards to prevent such
disclosure. Student acknowledges that any breach of confidentiality or misuse of information may result
in termination of Student's access to Facility, the potential termination of Facility's relationship with
Student's school and/or legal action. Unauthorized disclosure may give rise to irreparable injury to the
patient or the owner of the confidential information, and accordingly the patient or owner of such
information may seek legal remedies against the Student.
Fitness: Student shall provide documentary evidence that Student is fit for participation in the Clinical
Rotations as required by Facility policy. Student shall immediately notify Facility should any illness or
other health condition arise that may limit Student's participation in the Clinical Rotations.
Compliance with Policies and Rules: Student shall abide by all applicable rules, policies, and
instructions provided by Facility, whether verbal or written, while participating in the Clinical Rotations.
Student shall review the CORPORATION NAME’s Emergency Preparedness Information Brochure, as
provided by Facility, which includes information regarding bloodborne pathogens, hazardous chemicals,
TB prevention, fire safety, electrical safety, and emergency preparedness. Student agrees to wear
appropriate attire, including an identification badge identifying him/her as a student, if requested by
Facility.
Release: Student shall, to the extent allowed by law, hold harmless Facility, its parent CORPORATION
NAME, and any and all of their affiliates, subsidiaries, employees, agents, and insurers, from any and all
liability of whatsoever nature and from injuries, sickness, or other damages, physical as well as
emotional, suffered by Student during participation in the Clinical Rotations, unless caused by
CORPORATION NAME’S negligence.
Limitation: Student understands that by signing this Agreement, Student is not guaranteed participation
in any clinical activities at Facility. Facility in its sole discretion shall determine eligibility to participate.
Withdrawal of Unsatisfactory Student: Facility may require the Student to withdraw immediately from
Clinical Rotations if the Student's conduct, demeanor or cooperation is unsatisfactory to Facility as
determined by Facility in its sole discretion.
Assignment: This Agreement and/or rights, duties or obligations hereunder, may not be assigned by any
party hereto.
Date:___________________________ Student: __________________________________________