Indiana University Health, Inc/Fire/Affiliation Agreement DocuSign Envelope ID:A14CCA73-46BB-42C0-BE13-FF5102D4F087
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Affiliation Agreement \44Git
This Academic Affiliation Agreement("Agreement")is made this 14th day of March.2019("Effective 4,91
Date"),by and between Indiana University Health,Inc.("IU Health")and the City of Carmel,an
Indiana municipal corporation,by and through its Board of Public Works and Safety(the "City").
Recitals
A. City offers one or more educational programs listed on Exhibit A(collectively,the"Program").
B. City requires that certain students enrolled in Program complete a professional or clinical
education experience under the supervision a qualified clinical or other professional.
C. IU Health operates one or more clinical facilities("Facilities")listed on Exhibit B which provide
a setting for professional and clinical educational experiences.
D. City desires to partner with IU Health and its professionals to provide certain Program students
("Students")with a professional or clinical education experience at Facilities("Rotation"), and IU
Health desires to cooperate with the City by providing a Rotation to Students at Facilities.
Agreement
NOW,THEREFORE,in consideration of the premises and mutual covenants contained herein,the parties
hereto agree as follows:
Rotation Requirements
IU Health and City agree that the Rotation will be subject to the following requirements:
A. Representative. The parties shall each assign a point of contact for the Rotation to consult
with the other party on the matters described herein.
B. Student Limitation. IU Health and City agree that the Rotation 0 will El will not be limited
to Students who are current IU Health employees,with exceptions approved by IU Health.
C. Number of Students;Placement. The parties shall jointly agree upon the number of Students
to be placed at Facilities for the Rotation. The parties shall jointly agree upon the placement
of Students in the Rotation after consideration of the Students' needs and qualifications and
IU Health's resources.
D. Rotation Structure. The parties shall cooperate in developing the methods of instruction,
objectives,and other details of the Rotation.
E. Supervision. IU Health may require that Students are supervised or observed by one or more
Program faculty("Faculty"). City will identify qualified Faculty for such Programs.
F. Student and Faculty Requirements. All Students,and any Faculty required for supervision or
observation,are subject to all applicable policies of the IU Health, including without
limitation,IU Health's dress code, for the duration of the Rotation. Students and Faculty are
responsible for providing their own transportation and living arrangements during the
Rotation. Students must be at least eighteen(18)years of age.
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G. Student and Faculty Removal; Suspension;Termination. IU Health may suspend from the
Rotation any Student or Faculty who fails to comply with IU Health policies or with the
requirements of this Agreement. IU Health shall immediately notify the City of such
suspension. IU Health agrees to discuss any proposed Student or Faculty termination from
the Rotation with City;provided,however,IU Health has the right to terminate a Student or
Faculty from the Rotation if IU Health and City cannot reach agreement. Notwithstanding
anything in this Agreement to the contrary,the parties expressly acknowledge that IU Health
may immediately remove from Facilities and terminate from the Rotation any Student or
Faculty who poses an immediate threat or danger to patients, staff,visitors,the public, or the
premises.
II. IU HEALTH RESPONSIBILITIES
IU Health agrees to provide Students with an opportunity to obtain practical learning and clinical
experiences in Facility though the Rotation. In addition,IU Health shall:
A. Provide applicable IU Health policies,procedures,and regulations to Students and Faculty
via an initial orientation session.
B. Inform the City,through the City appointed representative,of any new or changed policies or
procedures which may affect Students,Faculty, or the Rotation.
C. Retain responsibility for IU Health patients.
D. Provide administrative and professional supervision of Students insofar as Students' presence
affects the operation of IU Health or the direct or indirect provision of services to IU Health
patients.
E. Provide access to emergency health care services to any Student or Faculty injured during the
Rotation,the cost of such health care services to be borne by the Student or Faculty.
F. Maintain all applicable accreditation requirements and certify such compliance to City or
other entity as requested by City.
G. Permit authorities responsible for accreditation of City or Program to inspect IU Health's
facilities or services as necessary,with reasonable prior notice.
III. CITY RESPONSIBILITIES
City agrees to assign Students to IU Health to obtain learning and clinical experiences through the
Rotation. In addition,City shall:
A. If required by IU Health for the Rotation,assign full-time appropriately certified Faculty who
shall coordinate Students' clinical experiences and assist IU Health in monitoring the quality
of care provided by Students.
B. Prior to assigning Students to IU Health for Rotation,submit a copy of the curriculum and
course content to IU Health for review.
C. Recommend for the Rotation only those Students who have successfully completed all
necessary requirements of the Program and are at least eighteen(18)years of age.
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D. Inform students of the policies and procedure provided by IU Health to City,and to such
other policies,procedures,rules,and regulations as City deems appropriate.
E. Inform students about the OSHA regulations pertaining to blood and air borne pathogens
before Students begin the Rotation.
F. Ensure that all Student and Faculty comply with the Rotation requirements described in this
Agreement.
G. Ensure that all Students and Faculty meet the following requirements prior to the beginning
of the Rotation(collectively,"Onboarding Requirements"):
1. Possess health or other insurance that is satisfactory to IU Health.
2. Pass a criminal background check(completed within the last twelve(12)months)
that meets the requirements described in Exhibit C attached hereto and incorporated
by reference.
3. Receive the following vaccinations: mumps,rubella,varicella,measles,tetanus,
diphtheria,pertussis, annual influenza and Hepatitis B(or declination form on file)or
shows appropriate antibody titer.
4. Pass a TB test(completed within the last twelve(12)months).
5. Pass a drug screen(at least a five panel screen)(completed within the last twelve(12)
months).
6. Complete fit testing(either qualitative or quantitative)for an N95 respirator, if
Student or Faculty will be working in a negative pressure room.
7. Obtain an American Heart Association Basic Life Support for Healthcare Providers
course or equivalent(evidenced by course completion card),if Student or Faculty
will be working in a clinical area.
H. Certify,and provide and retain documentation supporting, Students and Faculty compliance
with the Onboarding Requirements on a form substantially similar to that provided in Exhibit
D attached hereto and incorporated by reference(which may be subject to periodic audits by
IU Health).
I. Maintain institutional and programmatic accreditation,and advise IU Health of any change in
the approval or accreditation of City or Program.
J. Provide summative evaluation information about the Program and Student and Faculty
experiences to IU Health,upon request.
IV. COMPENSATION
The Rotation is considered an integral part of Student's formal education,and Student earns the right to be
employed by the City for participating. Accordingly, IU Health owes no compensation to Student,
Faculty,or City for Student or Faculty participation in the Rotation.
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V. INSURANCE
The parties shall carry the following insurance coverages at all times during the Agreement Tenn.
A. CITY GENERAL LIABILITY/WORKERS'COMPENSATION: City shall maintain: (i)
comprehensive general liability insurance in amounts equal to at least$1,000,000 per
occurrence and$3,000,000 annual in the aggregate;and(ii)if Faculty will be supervising or
observing Students,workers' compensation insurance in accordance with the applicable state
law,and employer's liability in the amount of$1,000,000.
B. CITY MEDICAL PROFESSIONAL LIABILITY: If Rotation is related to one of the health
care provider professions listed in I.C. 34-18-2-14,as amended from time to time,City shall
either:
1. (RECOMMENDED)Maintain a policy of professional liability insurance for itself,
Faculty, and Students with coverage in amounts necessary to continuously comply with
The Indiana Medical Malpractice Act("Act"),I.C. 34-18 et seq.,as amended,and pay the
applicable surcharge to the Indiana Department of Insurance such that City,Faculty,and
Students are Qualified Healthcare Providers under the provisions of the Act. City may
elect to require Students and Faculty to carry the required professional liability insurance,
unless the Students or Faculty are not licensed provider.
OR
2. Maintain a policy of professional liability insurance for itself,Faculty,and Students with
coverage in amounts equal to at least$1,000,000 per occurrence and$3,000,000 annual
in the aggregate. City may elect to require Students and Faculty to carry the required
professional liability insurance. City understands and acknowledges that Indiana's
limitation of liability on medical malpractice claims is only available to those that choose
option 1, above.
C. CITY OTHER PROFESSIONAL LIABILITY: If Rotation is not related to one of the health
care provider professions listed in I.C. 34-18-2-14,as amended from time to time,City shall
carry, or cause Students and Faculty to carry,commercially reasonable professional liability
coverage to the extent available.
D. City shall furnish the relevant certificates of insurance evidencing the coverages required
under this Agreement upon execution of this Agreement.
E. IU HEALTH INSURANCE REQUIREMENTS: IU Health shall maintain:(i)general
liability insurance of one million dollars($1,000,000.00)per occurrence or claim and three
million dollars($3,000,000.00)in the aggregate;(ii)workers' compensation insurance in
accordance with the laws of the State of Indiana,and employer's liability in the amount of
$1,000,000;and(iii)a policy of professional liability insurance with coverage in amounts
necessary to continuously comply with Act and pay the applicable surcharge to the Indiana
Department of Insurance such that it is a Qualified Healthcare Provider under the provisions
of the Act.
F. IU Health shall furnish the relevant certificates of insurance evidencing the coverages
required under this Agreement upon execution of this Agreement.
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VI. RELATIONSHIP OF THE PARTIES
Nothing in this Agreement is intended to,nor shall it be construed so as to make,either party the agent or
servant of the other for any purpose whatsoever. Neither party by virtue of this Agreement assumes any
responsibility for any debts or obligations of the other party to this Agreement. The parties expressly
acknowledge that Students and Faculty are not IU Health employees and therefore are not entitled to any
IU Health employee benefits, including without limitation,compensation, Social Security benefits,health
insurance benefits,or Worker's Compensation benefits. The parties further acknowledge that Students
are not entitled to future employment by IU Health.
VII. INDEMNIFICATION;LIMITATION OF LIABILITY
A. Indemnification. To the extent allowable by relevant state statute,the City agrees to
indemnify and hold harmless IU Health from any damages,attorney fees or other costs IU
Health may incur as a result of claims,demands, or other losses arising out of the acts or
omissions of City,Faculty or Students. IU Health agrees to indemnify and hold harmless the
University from damages, or other costs the City shall incur as a result of claims,arising out
of the negligent acts or omissions of IU Health or its employees. If either party becomes
aware of a claim or threatened claim involving the other party,the party with knowledge of
the claim or threatened claim shall inform the other party in writing within ten(10)days of
receiving knowledge of the claim or threatened claim.
B. Limitation of Liability. The parties agree certain Facilities in which a Rotation may take
place are not be owned by IU Health and are operated by IU Health pursuant to an agreement
with a third party(each,a"Third Party Facility"). The City expressly acknowledges that IU
Health does not own or control Third Party Facility,and City agrees IU Health is not liable
for breach of this Agreement, including without limitation,failure to permit City access to
Third Party Facility,to the extent such breach is caused by the Third Party Facility.
VIII. CONFIDENTIALITY
Neither party("Receiving Party")will disclose or use any proprietary or confidential information or
materials of the other party("Disclosing Party"), including without limitation, information about the
Disclosing Party's customers,patients, students,faculty, practices,procedures,strategies,organization,
fmancials or other related information("Confidential Information"),except as may be required to carry
out the Receiving Party's duties and responsibilities under this Agreement,or as may be required by law.
IX. PUBLICITY
City, Students,and Faculty shall not publish,or put forth intended for publication,any material that
makes reference to IU Health, its employees,patients, or operations, or Facilities,without prior written
approval by IU Health.
X. COMPLIANCE
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A. Compliance with Applicable Law; Student Records. The parties shall comply in all material
respects with all federal and state mandated regulations,rules or orders applicable to the
parties, including without limitation,regulations required by their respective accreditation
bodies and those promulgated under the Family Educational Rights and Privacy Act of 1974
governing the privacy of student records. IU Health agrees to protect Student personally
identifiable information and education records from disclosure and report any breach of such
personally identifiable student information or educational records to City. Upon termination,
cancellation, expiration or other conclusion of the Agreement,IU Health shall securely store
or destroy Student education records in accordance with its retention policies.
B. Protected Health Information. The parties acknowledge that regulations promulgated under
the Health Insurance Portability and Accountability Act of 1996("HIPAA")require covered
entities like IU Health to comply with certain privacy and security requirements associated
with the transfer,use or disclosure of protected health information and electronic protected
health information(collectively referred to herein as"PHI"). City shall direct Students to
comply with the policies and procedures of IU Health, including those governing the use and
disclosure of PHI under HIPPA. Solely for the purpose of defusing their role in relation to
the use and disclosure of IU Health's PHI, Students are defined as members of IU Health's
workforce, as that term is defined by 45 CFR 160.103,when engaged in activities pursuant to
this Agreement. However,Students are not and shall not be considered to be employees of
IU Health.
C. Nondiscrimination. The parties agree to comply with Title VI and IX of the Federal
Education Amendments of 1972, Section 504 of the Federal Rehabilitation Act of 1973,
Executive Order 11,246 and the related regulations,and the parties further agree they will not
discriminate against any employee,applicant for employment, student,or applicant for
admission on the basis of race,religion,ethnic or national origin,gender,sexual orientation,
marital status,age,disability,or veteran status.
XI. TERM AND TERMINATION
A. Term. This Agreement shall commence on the Effective Date and shall remain in effect until
June 30,2020("Initial Term"). Thereafter,this Agreement can be renewed upon like terms
for additional one(1)year periods(each,a"Renewal Term")via an annual letter of renewal
initiated by City and approved in writing by IU Health,the number of Renewal Terms not to
exceed four(4). The Initial Term and all Renewal Terms may be referred to collectively as
the"Term."
B. Termination without Cause. Either party may terminate this Agreement without cause at any
time during by giving ninety(90)days prior written notice to the other party;provided that
Students shall be given an opportunity to complete the Rotation, if reasonably practicable.
C. Immediate Termination. Notwithstanding anything in this Agreement to the contrary, either
party may immediately terminate this agreement upon the occurrence of any of the following
events:
1. Either party is suspended,debarred, or excluded from participation in any
government healthcare program;
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2. The required license(s), certification(s),or accreditation(s)of either party are
suspended or revoked;or
3. The terminating party reasonably believes that such termination is necessary to
protect the health and safety of patients.
XII. MISCELLANEOUS
A. Notice. Any notice required under this Agreement shall be given in writing,and hand
delivered or sent via registered or certified mail,postage pre-paid,return receipt requested, or
by a nationally recognized overnight courier service,to the address provided below.
IU Health City
IU Health Academic Affairs Cannel Fire Department
I-65 at 21st Street 2 Civic Square
P.O.Box 1367 Cannel,IN 46032
Indianapolis, IN 46206-1367 Attn: Andrew Young,EMS Captain
Attn: Mark Mattes
With Copy To: With a Copy To:
IU Health Office of the General Counsel Douglas C.Haney,Corporation Counsel
340 W 10th Street,FS 6100 1 Civic Square
Indianapolis, IN 46202 Cannel,IN 46032
Either party may change the notification addresses listed by providing written notice.
B. Governing Law. This Agreement shall be governed by and construed pursuant to the laws of
the State of Indiana,without giving effect to the principles of choice of law of any state.
C. Amendment;Modification for Change in Law. Any amendments to this Agreement shall be
effective only if in writing and signed by authorized representatives of both parties. To the
extent that any law,rule, or regulation of any authority having jurisdiction over the parties
shall raise question as to the legality,enforceability,or appropriateness of this Agreement or
any provision hereof,the parties agree in good faith to renegotiate the problematic
provision(s)to bring this Agreement into compliance with such applicable law,rule,or
regulation. If the parties are not able to mutually agree on modification of the problematic
provision(s),then notwithstanding anything to the contrary herein,either party may terminate
this Agreement immediately under this Section upon written notice to the other party.
D. Assignment. Neither party may assign this Agreement or the rights or obligations hereunder
without the prior written consent of the other party.
E. Entire Agreement. This Agreement constitutes the entire agreement and understanding
between the parties with respect to the subject matter hereof and supersedes any previous
agreements or understandings,whether oral or written.
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F. Execution. The person or persons signing and executing this Agreement on behalf of each
party do hereby warrant and guarantee that they have been fully authorized by such party to
execute this Agreement on behalf of the party and to validity and legally bind the party to all
terms,performances,and provisions set forth in the Agreement. Signatures transmitted by
facsimile or other electronic means shall be accepted as original signatures.
G. Headings. The headings in this Agreement are for reference only and shall not affect the
interpretation of this Agreement.
H. Waiver.The failure of a party in any instance to insist upon the strict performance of the
terms of this Agreement shall not be construed to be a waiver or relinquishment of any of the
terms of this Agreement, either at the time of the parry's failure to insist upon strict
performance or at any time in the future,and such term or terms shall continue in full force
and effect.
[Remainder of Page Intentionally Blank;Signatures Follow.]
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IN WITNESS WHEREOF,the parties have executed this Agreement effective as of the day and year
indicated above.
Indiana University Health,Inc. City of Carmel, by and through its Board of
IU Health Public Works and Safety
DocuSigned by:
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Name: Mark Mattes,JD Name: James Brainard
Title: Executive Director,Academic Affairs Title: Presiding Officer
7/2/2019 7 " //
Date: Date:
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Name: Mary Ann Burke
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Member
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By:
Name: Lori S.Watson
Title: Member
Date: rl 11 1 I 1 9
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EXHIBIT A—UNIVERSITY PROGRAMS
Program Name University Campus
EMT Program Cannel Fire Department
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EXHIBIT B—IU HEALTH FACILITIES LIST
Indiana University Health North Hospital
11700 N.Meridian Street
Cannel,IN 46032
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EXHIBIT C—IU HEALTH BACKGROUND CHECK REQUIREMENTS
Background Check Information
To fully understand the circumstances that can disqualify a Student or Faculty from participating in an IU
Health educational experience,please be aware of how we define and use the following terms:
• Conviction: Any violation of a law or ordinance for which an individual was found guilty by a
judge or jury,pleaded no contest or to which the individual pleaded guilty.
• Falsification: Providing or omitting information contrary to that obtained in a background
investigation(unless the background investigation is proven to be inaccurate)and/or providing
false, incomplete or misleading information.
Consistent with IC 16-28-13,the following convictions will disqualify a Student or Faculty from
participating in a Rotation at IU Health:
1. A sex crime
2. Exploitation of an endangered adult
3. Failure to report battery,neglect,or exploitation of an endangered adult
4. Theft,* if the prospective student's conviction of theft occurred less than five(5)years before
the prospective student's application**
5. Murder
6. Voluntary manslaughter
7. Involuntary manslaughter within the previous five(5)years**
8. Battery within the past five(5)years**
9. A felony offense relating to controlled substances within the last five(5)years**
10. Abuse or neglect of a minor,child or dependent
11. Failure to report the abuse of a minor,child or dependent
12. Any act that, if it occurred at the organization,could compromise the safety or well-being of
patients,employees,visitors,or volunteers of the organization
* Theft includes but is not limited to criminal conversion,receiving stolen property, shoplifting and
identity theft.
**Time frames are measured from the date of disposition(conviction).
The following events will disqualify a Student or Faculty from participating in a Rotation at IU
Health:
1. A Student or Faculty who has abused,neglected,or mistreated a patient or misappropriated a
patient's property,as reflected in the state nurse aide registry.
2. A Student or Faculty whose name appears in a Sex Offender Registry.
3. A Student or Faculty who falsifies information.
Federal Exclusions Lists
Background checks must include the checking of the Federal Exclusions Lists. The exclusions lists
include:
• Office of Inspector General(OIG)U.S.Department of Health and Human Services: The
OIG,under a Congressional mandate,established a program to exclude individuals and entities
affected by various legal authorities,contained in sections of the Social Security Act,and
maintains a list of all currently excluded parties called the"List of Excluded Individuals/Entities"
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• The System for Award Management(SAM)—General Services Administration: The System
for Award Management(SAM)is combining federal procurement systems and the Catalog of
Federal Domestic Assistance into one new system which contains:
- Central Contractor Registry(CCR): The Central Contractor Registration(CCR.GOV)
is the primary vendor database for the U.S.Federal Government. The CCR collects,
validates, stores and disseminates data in support of agency acquisition missions.
- Federal Agency Registration(FedReg):FedReg collects standard data on federal
agency buyers and sellers who perform intragovernmental transactions.FedReg sends
data on buyers and sellers to the Intragovernmental Transaction Exchange and
Intragovernmental Transaction System to assist in tracking all intragovernmental
transactions. FedReg also serves as a sort of government"Yellow Pages," providing
information on federal sellers of goods and services. All federal entities engaged in
intragovernmental buying or selling must be registered.
- Online Representations and Certifications Application(ORCA): ORCA is a Federal
Acquisition Regulations(FAR)mandated web-based system that streamlines the
solicitation and award process for both vendor and Government by collecting vendor
representations and certifications of business information that is required by law for
contract award.
- Excluded Parties List System(EPLS)U.S.General Services Administration: EPLS
is an electronic,web based system that identifies those parties excluded from receiving
federal contracts,uncertain subcontractors,and certain types of federal financial and non-
financial assistance and benefits.
• Specially Designated Nationals List(SDN)U.S.Department of Treasury: List of individuals
and companies owned or controlled by, or acting for or on behalf of, targeted countries. The
SDN also lists individuals,groups, and entities such as terrorists and narcotics traffickers
designated under programs that are not country-specific.
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EXHIBIT D—IU HEALTH CLINICAL STUDENT/FACULTY VALIDATION FORM
University and Educational Program:
Student or Faculty Name:
This Form must be completed by the University for each Student or Faculty participating in a Rotation at IU Health.
All source documentation not required by this Form must be kept on file at the University and must be produced in
24 hours of a request by IU Health. This completed Form and supporting documentation must be submitted to IU
Health prior to the Student or Faculty beginning a Rotation.
If the Student or Faculty is a current IU Health employee,University may submit the name(s)to RI Health. Upon
IU Health's written verification to University by IU Health of current employment status,University will not be
required to collect and submit to IU Health the information in Section 2 below.
Section 1:
• Medical Insurance(Company and Policy Number):
• CPR cert expires(if applicable):
• N 95 fit testing(if applicable):
Section 2:
• Criminal Background and Federal Exclusions check: Please attach copy of report
• MMR vaccines:MMR 1 MMR 2
• Rubella AB titer :
• Rubeola measles AB titer:
• Mumps AB titer:
• Diphtheria,tetanus,pertussis vaccine:
• Annual Influenza vaccine(must be for the current flu season):
• Hepatitis vaccine or titer(or declination form):Dose 1 Dose 2 Dose 3
• Varicella Vaccine or titer:
• Annual TB test(Date and results):
• Drug screen Results(Attach copy of the report):
I certify that this information is correct and accurate, and I have verified documentation. Supporting
documentation is on file at the University named above and available upon request.
University Official Signature Title Date