HHA Affiliation Agreement Requirements

BPSS-39, updated 05/2018

A signed affiliation agreement must be submitted 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.

  1. Specific name and location of the proprietary school.
  2. 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.
  3. 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.
  4. Number of students to be supervised during one affiliation period.
  5. Process for verification for attendance at the affiliation site.
  6. Assurance that students will not displace or replace regular employees.
  7. The school agrees to maintain sufficient affiliation sites to accommodate all qualified students in the class.
  8. School is responsible for insuring students had a physical exam within 6 months before starting the internship, and all inoculations recommended in the profession.
  9. Before a new group of students start their internship, school and internship site must exchange a copy of the schedule, showing the date and place at which, each student will intern. The schedule must be signed by the internship site. That signed list is to be kept by the school.
  10. Provision for insuring the student against injuries resulting from the internship.
  11. Provision that 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.
  12. The school is responsible for providing all theory/practice instruction.
  13. The school will use the Dept. of Health SKILLS checklist at the internship site.
  14. Students will be supervised at ALL times during affiliation by your Registered Nurse.
  15. Provision for school visitation and/or oversight of the internship site.
  16. Provision for ensuring proper student conduct at the internship site.
  17. Provision for Specific conditions and procedures for terminating a student.
  18. Provision for either party to terminate the affiliation agreement.
  19. Provision for the language of the internship.  If the training was in a language other than English, the affiliation school must ensure that the internship site has employees and clients conversant in that language with which the intern will work.
  20. A newly signed agreement must be sent with your curriculum reapproval.

Sample Affiliation Agreement