OCCUPATIONAL THERAPY PROGRAM
AFFILIATION AGREEMENT
BETWEEN
CHICAGO STATE UNIVERSITY AND (SITE NAME)
This Affiliation Agreement (hereinafter "the Agreement") is entered into by and between
CHICAGO STATE UNIVERSITY, 9501 S. King Drive, Chicago, Illinois 60628-1598
(hereinafter "the University") AND SITE NAME, ADDRESS, CITY, STATE, ZIPCODE
(hereinafter “the Facility”) as of this ____ day of MONTH, YEAR
The purpose of this Affiliation Agreement is to establish the terms and conditions by which
the Facility shall provide fieldwork education experiences in its Occupational Therapy
Department for the University's occupational therapy students.
The parties recognize that both academic and clinical institutions have vested interests in
providing structured fieldwork experiences and educational activities for occupational
therapy students. By agreeing to cooperate in accomplishing these common interests, the
parties hope to further mutual understandings and programs of mutual interest, to further
professional growth and competence of occupational therapy students and practitioners, to
further the availability of much needed manpower and to further excellence and
competence in the delivery of occupational therapy services to clients.
Therefore, the parties agree as follows:
A.
University Responsibilities:
(1)
The University shall admit only those students to its Occupational Therapy
Program ("the OT Program") who have completed all programmatic prerequisite
courses and who have competed successfully with other applicants for a position in
each annual class. Admission shall be open to University students as well as to
students who may transfer to the University from other educational institutions.
The Occupational Therapy Admission Committee shall direct both the admission
process and the evaluation of courses for transfer credit.
(2)
The University shall provide and maintain during the term of this Agreement a
policy of comprehensive professional liability insurance with limits of $1,000,000
(occurrence) and 3,000,000 (aggregate) which insurance shall be evidenced by a
certificate of insurance furnished to the Facility.
(3)
The university shall provide the services of an Occupational Therapy Program
Director/Fieldwork Coordinator (“the program Director”) as a liaison between the
university and Facility. The Program Director’s duties to the Facility shall include
but shall not be limited to the following:
(a) providing the student data sheets on each University student scheduled to
affiliate at the Facility not less than two weeks prior to said student’s
commencement of affiliation,
(b) planning visits and consultations between the University’s program faculty and
the Facility as are necessary to promote exchange of information relevant to a
student’s fieldwork education experience at the Facility,
(c) providing evidence reasonably satisfactory to the Facility that all matriculating
students carry student professional liability insurance,
(d) advising students of their responsibilities during the fieldwork education at the
Facility including their obligation to keep confidential all patient information to
which they gain access in the course of their fieldwork experience, and,
(e) referring to the Facility only those students who have satisfactorily completed
the prerequisite didactic portion of the curriculum, which is applicable to the
Facility.
(4)
The University shall grant the Facility’s Occupational Therapy Director a courtesy
adjunct appointment to the University faculty.
(5)
The university shall assure the Facility that students assigned to the Facility meet
both University and Facility standards of health.
B. Facilities Responsibilities:
(1)
The Facility shall designate a staff member acceptable to the University as Clinical
Instructor (“the Clinical Instructor”). The Clinical Instructor’s duties shall include
but shall not be limited to the following:
(a) coordinating and directing each University student’s fieldwork education,
(b) providing a planned fieldwork experience that meets the requirements set forth
hereinafter in section C(10),
(c) providing orientation for University personnel and students to the Facility,
(d) providing notice, by midterm of fieldwork assignment to the University’s
Program Director of any situation or problem which may threaten student’s
successful completion of his/her fieldwork education, and
(e) providing an evaluation for students engaged in fieldwork education at the
Facility in the manner prescribed by the University’s Program Director and the
American Occupational Therapy Association.
(2)
The Facility shall provide reasonable student facilities such as classrooms,
conference rooms and other available study and storage space.
(3)
The Facility shall make available to the students the Facility’s library facilities.
(4)
The Facility shall provide educational experiences in selected services and units of
the Facility, allowing the student to participate as determined by applicable policies
of the Facility.
(5)
The Facility shall make available to students other Facility learning experiences
such as ward rounds, staff conferences, in-service education and similar activities, at
the discretion of the Clinical Instructor.
(6)
The Facility shall provide adequate student supervision by registered occupational
therapists or qualified staff (as mutually agreed upon) and maintain an adequate
level of staff support to carry out normal service function so that students will not
be expected to perform client services in lieu of staff.
(7)
The Facility shall provide the University with a list of all personnel supervising
students or otherwise participating in the student’s fieldwork education experience,
which list shall include said personnel’s professional and academic qualifications.
(8)
All records kept by the hospital relating to a student’s performance shall be made
available to the parties hereto and to the student, and not to other persons, as
required by the Family Education rights and Privacy Act of 1974, 20 U.S.C. 1212(g).
(9)
Pursuant to the requirements of the Illinois Drug Free Workplace Act, the
Contractor, if a corporation, partnership, or other business entity having twentyfive employees at the time of letting this Agreement, will provide a drug free
workplace by taking certain steps prescribed in the Act.
Joint Responsibilities:
(1)
There shall be no discrimination or intimidation against students on account of race,
creed, color, sex, religion, physical or mental handicap unrelated to ability, or
national origin in employment under contracts for public buildings or public works
(775 ILCS 10/0 1 et seq.) The provisions of this Act are made a part of this contract
by reference as though set forth in full herein.
(2)
The number of students, dates of assignments and availability of the Facility
fieldwork education opportunities shall be determined by the Clinical Instructor
and Program director.
(3)
The students shall be advised and required to adhere to the rules and regulations of
the Facility, including observation of the Facility’s hours of work and dress
standards, and participation in Occupational Therapy Department activities,
including after-hours and in-service education programs and continuing education
opportunities.
(4)
Each party shall inform the other in a reasonable time of the following:
(a) changes in academic curricula,
(b) changes in the availability of learning opportunities, and
(c) staff changes affecting either academic preparation or clinical teaching of
students.
(5)
Either the Facility or University may request withdrawal of a student from
fieldwork assignments. The party requesting such withdrawal shall give written
notification of such withdrawal to the other party and the student. Such withdrawal
shall occur only upon the following terms and conditions:
(a) The Program Director shall review the student’s record and other appropriate
items and shall afford the student an opportunity to respond to allegations
against him/her before any disciplinary action is taken.
(b) Academic suspension of students shall be based on University policy.
(c) A student who withdraws or is terminated shall be permitted to repeat that
course one time.
(6)
Reports, data, self-studies and other reasonable information that may be requested
by either party or reasonable information that may be required by the
Accreditation Committee of the American Occupational Therapy Association, the
Committee on Allied Health Education and Accreditation, the North Central
Association of Colleges and Secondary Schools or other relevant professional
accrediting agencies or governmental bodies shall be completed and exchanged
between parties as necessary.
(7)
Students must enroll in fieldwork courses at the university. A student may enroll in
fieldwork courses only after the Program Director and University Faculty has
evaluated his/her credentials and he/she has been accepted into the University’s OT
Program.
(8)
Cooperative effort is required between the Facility’s Clinical Instructor and the
university’s Program Director regarding the following:
(a) scheduling of fieldwork experiences
(b) assignments of students in the fieldwork program
(c) providing pertinent schedules, dress and/or uniform regulations and establishing
the level of professional standards for students
(d) implementing the standardized fieldwork evaluation and grade policies for
students,
(e) developing professional curriculum and course objectives, and
(f) periodically evaluating and
professional course objectives.
(9)
revising the
professional
curriculum and
Any modification or recommended changes in the occupational therapy curriculum
must be approved by the appropriate faculty and administrative of the university as
follows:
(a) changes of course content, instructors or scheduling shall be decided at the
departmental level through usual University channels
(b) major modifications of curriculum shall require approval of the College
Curriculum Committee, the Dean of the college of Health Sciences and, where
applicable, the Graduate Council
(c) the parties must agree to any changes or modifications in the curriculum, which
shall affect the rights or duties of either party to the Agreement.
(10)
The OT Program (including the academic phase and the professional phase) shall
conform to the Standards of an Accredited Educational Program for the
Occupational Therapist as adopted by the Accreditation Council for Occupational
Therapy Education.
(11)
It is understood that neither party to this Agreement shall be liable for any negligent
or wrongful acts, either of commission or omission, chargeable to the other, unless
such liability is imposed by law, and that this Agreement shall not be construed as
seeking to either enlarge or diminish any obligations or duty owed by one party
against the other or against a third party.
C. The Agreement
(1)
The term of this Agreement shall begin on ______________. The Agreement shall
be renewed every three years by mutual written agreement of both parties. This
Agreement may be terminated, at any time, by either party giving written notice of
such termination to the other at least sixty (60) days prior to the desired termination
date.
(2)
Should the Accreditation Council deny its Accreditation of the University’s OT
Program, this Agreement shall terminate at the conclusion of the then existing
academic year.
(3)
This Agreement shall be governed in all respects by the laws of the State of Illinois.
D.
Modification, Amendment and Assignment:
The terms of this Agreement may not be modified, amended or assigned unless such
modification, amendment or assignment is agreed to in writing by both parties and
affixed hereto as amendment(s).
In witness whereof the parties have entered into the Affiliation agreement as of the dates
first set forth above.
“THIS DOCUMENT IS INVALID UNLESS SIGNED AND DATED BY THE
PRESIDENT OF CHICAGO STATE UNIVERSITY”
CHICAGO STATE UNIVERSITY
FACULITY NAME
BY___________________________
Dr. Wayne D. Watson, President
BY___________________________
(SIGNATURE)
_____________________________
(please print name)
DATE _______________________
DATE ________________________
AFFILIATION AGREEMENT
BETWEEN
CHICAGO STATE UNIVERSITY AND (SITE NAME)
This Affiliation Agreement (hereinafter " the Agreement") is entered into by
And between CHICAGO STATE UNIVERSITY, 9501 S. King Drive, Chicago, Illinois 606281598 (hereinafter "the University") and SITE NAME, ADDRESS, CITY, STATE, ZIPCODE
(Hereinafter "the Facility") as of this ____ day of MONTH, YEAR
The purpose of the Affiliation Agreement is to establish the terms and conditions by which the
Facility shall provide fieldwork education for the University's occupational therapy students.
The parties recognize that both academic and clinical institutions have vested interests in
providing structured fieldwork experiences and educational activities for occupational therapy
students. By agreeing to cooperate in accomplishing these common interests, the parties hope to
further mutual understandings and programs of mutual interest, to further professional growth
and competence of occupational therapy students and practitioners,
to further the availability of manpower and to further excellence and competence in the delivery
of occupational therapy services to clients.
Therefore, the parties agree as follows:
A.
University Responsibilities:
The University shall, at its own cost and expense, obtain and maintain during the term of
this Agreement general and professional liability insurance with limits of 1 million
(occurrence) and 3 million (aggregate). Such insurance shall be evidenced by a certificate
furnished to the Facility.
(1)
The University shall provide the services of an Occupational Therapy Program
Director/Fieldwork Coordinator ("the program Director") as a liaison between the
University and Facility. The Program Director's duties to the Facility shall include but
shall not be limited to the following:
(a) providing the student data sheets on each University student scheduled to
affiliate at the facility not less than two weeks prior to said student's commencement of
affiliation,
(b) planning visits and consultations between the University's program faculty
and the Facility as are necessary to promote exchange of information
relevant to a student's fieldwork education experience at the Facility,
(c) advising students of their responsibilities during the fieldwork education at
the Facility including their obligation to keep confidential all client/facility information
to which they gain access in the course of their fieldwork experience.
(2)
All students assigned to or making use of any area of the facility will meet
health requirements of the facility.
E. Facilities Responsibilities:
(10)
The Facility shall designate a staff member acceptable to the University as Clinical
Instructor or Contact Person (“the Clinical Instructor”). The Clinical Instructor’s
duties shall include but shall not be limited to the following:
(f) providing orientation for University personnel and students to the Facility,
(g) providing notice, in a timely manner, to the University’s Program Director of
any situation or problem which may threaten student’s successful completion of
his/her fieldwork education, and
(h) providing feedback for evaluation of students engaged in fieldwork education at
the Facility
(11)
The Facility shall provide the University with a list of personnel supervising
students or otherwise participating in the student’s fieldwork education experience,
which list shall include said personnel’s professional and academic qualifications.
(12)
All records kept by the facility relating to a student’s performance shall be made
available to the parties hereto and to the student, and not to other persons, as
required by the Family Education rights and Privacy Act of 1974, 20 U.S.C. 1212(g).
(13)
Pursuant to the requirements of the Illinois Drug Free Workplace Act, the
Contractor, if a corporation, partnership, or other business entity having twentyfive employees at the time of letting this Agreement, will provide a drug free
workplace by taking certain steps prescribed in the Act.
Joint Responsibilities:
(12)
There shall be no discrimination or intimidation against students on account of race,
creed, color, sex, religion, physical or mental handicap unrelated to ability, or
national origin in employment under contracts for public buildings or public works
(775 ILCS 10/0 1 et seq.) The provisions of this Act are made a part of this contract
by reference as though set forth in full herein.
(13)
The number of students, dates of assignments and availability of the Facility
fieldwork education opportunities shall be determined by the Facility supervisor
and Program director.
The students shall be advised and required to adhere to the rules and regulations of
the Facility, including observation of the Facility’s hours of work and dress
standards.
(14)
(15)
It is understood that neither party to this Agreement shall be liable for any negligent
or wrongful acts, either of commission or omission, chargeable to the other, unless
such liability is imposed by law, and that this Agreement shall not be construed as
seeking to either enlarge or diminish any obligations or duty owed by one party
against the other or against a third party.
F. The Agreement
(4)
The term of this Agreement shall begin on ________________. The Agreement shall
be renewed every three years by mutual written agreement of both parties. This
Agreement may be terminated at any time by either party giving written notice of
such termination to the other at least sixty (60) days prior to the desired termination
date.
(5)
Should the Accreditation Council deny its Accreditation of the University’s OT
Program, this Agreement shall terminate at the conclusion of the then existing
academic year.
(6)
This Agreement shall be governed in all respects by the laws of the State of Illinois.
G.
Modification, Amendment and Assignment:
The terms of this Agreement may not be modified, amended or assigned unless such
modification, amendment or assignment is agreed to in writing by both parties and
affixed hereto as amendment(s).
In witness whereof the parties have entered into the Affiliation agreement as of the dates
first set forth above.
“THIS DOCUMENT IS INVALID UNLESS SIGNED AND DATED BY THE
PRESIDENT OF CHICAGO STATE UNIVERSITY”
CHICAGO STATE UNIVERSITY
BY___________________________
Dr. Wayne D. Watson, President
FACILITY NAME
BY_____________________________
(Signature)
_____________________________
(PLEASE PRINT NAME)
DATE _______________________
DATE _________________________