CTE Clinical Site Affiliation Agreement

Tri-party agreement for student clinical placements at a healthcare facility, defining responsibilities, supervision, liability, and compliance expectations.

Agreement Purpose and Submission Notice

• Agreement Type
• I confirm I am authorized to submit this agreement on behalf of my organization
• Privacy and data minimization acknowledgment
  I understand this form should only collect minimum-necessary information for the affiliation agreement and may create an audit trail of submission and approval activity.

Participating Organizations

• School or District Name
• Healthcare Facility Name
• CTE Program Name
• Primary School Contact Email
• Facility Contact Email

Clinical Placement Scope

• Proposed Placement Start Date
• Proposed Placement End Date
• Student Level
• Clinical Setting
• Allowed Student Activities
• Restricted Activities
  List any activities students may not perform at this site.

Supervision, Compliance, and Safety

• Supervision Model
• Will the facility assign a preceptor or clinical mentor?
• Required Student Training or Clearances
• Facility orientation required before student placement begins
• Emergency Procedure Summary
  Briefly describe incident reporting, emergency response, and escalation contacts for student placements.

Liability, Insurance, and Confidentiality

• Liability and risk acknowledgment
  The parties acknowledge that clinical education involves inherent risks and agree to the liability terms established in the affiliation agreement.
• Insurance coverage required by the facility
• Confidentiality and HIPAA acknowledgment
  Students and participating staff must protect patient information and comply with HIPAA and facility confidentiality policies.
• Incident Reporting Contact

Signatures and Authorization

• School Authorized Signer Name
• Facility Authorized Signer Name
• Program Coordinator Name
• School Signature
• Facility Signature
• Program Coordinator Signature