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Run: CTE Clinical Site Affiliation Agreement

CTE Clinical Site Affiliation Agreement template for student placements at healthcare facilities. Use it to define supervision, scope, liability, and confide...

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Agreement Purpose and Submission Notice

Agreement Type (required)

I confirm I am authorized to submit this agreement on behalf of my organization (required)

Yes No N/A

Privacy and data minimization acknowledgment (required)

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.

Yes No N/A

Participating Organizations

School or District Name (required)

Healthcare Facility Name (required)

CTE Program Name (required)

Primary School Contact Email (required)

Facility Contact Email (required)

Clinical Placement Scope

Proposed Placement Start Date (required)

Proposed Placement End Date (required)

Student Level (required)

Clinical Setting (required)

Allowed Student Activities (required)

Restricted Activities

List any activities students may not perform at this site.

Supervision, Compliance, and Safety

Supervision Model (required)

Will the facility assign a preceptor or clinical mentor? (required)

Required Student Training or Clearances (required)

Facility orientation required before student placement begins (required)

Yes No N/A

Emergency Procedure Summary (required)

Briefly describe incident reporting, emergency response, and escalation contacts for student placements.

Liability, Insurance, and Confidentiality

Liability and risk acknowledgment (required)

The parties acknowledge that clinical education involves inherent risks and agree to the liability terms established in the affiliation agreement.

Yes No N/A

Insurance coverage required by the facility (required)

Confidentiality and HIPAA acknowledgment (required)

Students and participating staff must protect patient information and comply with HIPAA and facility confidentiality policies.

Yes No N/A

Incident Reporting Contact (required)

Signatures and Authorization

School Authorized Signer Name (required)

Facility Authorized Signer Name (required)

Program Coordinator Name (required)

School Signature (required)

Facility Signature (required)

Program Coordinator Signature (required)

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