Affiliation Agreement Requirements - HHA
BPSS-31, updated 10/2018
A signed affiliation agreement must be submitted and approved for each internship site. The following information/conditions must be included in the agreement. You can choose to use the sample agreement below. A separate agreement exists for Nurse Aides, Ultrasound, and general programs.
- Specific name and location of the proprietary school
- Specific name and location of the internship site AND a photocopy of its operating certificate/license. The site can also be an assisted living facility or adult home, but not a nursing home or adult day care.
- Exact dates/or total length, in hours, of the affiliation experience. The regular period is 8 hours, which can be split into 2 half-days. Some schools choose to have longer periods.
- Number of students to be supervised during one affiliation period
- That the school is responsible for taking attendance at the affiliation site
- Students will not displace or replace regular employees
- The school agrees to maintain sufficient affiliation sites to accommodate all qualified students in the class.
- School is responsible for insuring students had a physical exam within 6 months before starting the internship, and all inoculations recommended in the profession.
- Before a new group of students start their internship, school and host must exchange a copy of the schedule, showing the date and place each student will intern at. The schedule must be signed by the host. That signed list is to be kept by the school.
- School or Internship site (usually the school) is responsible for insuring the student against injuries resulting from the internship. [If the school insurance does not cover the internship site, the school either buys insurance for interns and rolls that insurance into the tuition or makes available to interns the purchase of such insurance coverage. In the latter case, the fact that students must buy their own accident insurance must be noted in the enrollment agreement, and the name of the company, the extent of coverage, and the cost to students must be noted in the Affiliation Agreement]
- Your students and instructors will be covered by liability insurance against liability for injuries/damage towards third parties (such as patients) arising from the Internship. The insurance carrier, cost and exact insurance coverage must be identified.
- The school is responsible for providing all theory/practice instruction.
- The school will use the Dept. of Health SKILLS checklist at the internship site.
- Students will be supervised at ALL times during affiliation by your Registered Nurse.
- How often the school’s program coordinator will visit the affiliation site.
- The school is responsible for the conduct of the students at the affiliation site.
- Specific conditions and procedures for terminating a student.
- How much notice must be given by either party to terminate the agreement.
- If the training was in a language other than English, the affiliation institution must declare that there are clients conversant in that language for the intern to work with. This must be added to the text.
- A newly signed agreement must be sent with your curriculum reapproval.