HomeMy WebLinkAboutItem #04 Approval of Agmt. Between Ocoee and Valencia Community College
AGENDA ITEM COVER SHEET
Contact Name:
Contact Number:
Richard Firstner
407 -905-3126
Meeting Date: August 5,2008
Item # 4-
Reviewed By:
Department Director: Richard Firstner
City Manager: Robert Frank
Subject:
APPROVAL OF AGREEMENT BETWEEN CITY OF OCOEE AND
VALENCIA COMMUNITY COLLEGE.
Background Summary:
The Ocoee Fire Department is seeking an agreement with Valencia Community College to provide supervised
learning experiences for the College's emergency medical services students. The department will become a
clinical training ground to precept students in the field while riding on City engines and rescues.
Issue:
The City of Ocoee Fire Department will utilize its facilities to provide clinical experiences for students enrolled in
the College's emergency medical services program, utilizing the approved program of study. The term of the
agreement is through December 31, 2010 and may be extended by agreement of both parties.
Recommendations
It is the recommendation of the Ocoee Fire Department that the City of Ocoee adopt the agreement between
the City of Ocoee and Valencia Community College.
Attachments:
Three sets of the agreement, to be signed and returned to Valencia Community College
Financial Impact:
There is no financial impact to either party.
Type of Item: (please mark with an "x'J
Public Hearing
_ Ordinance First Reading
Ordinance Second Reading
Resolution
Commission Approval
Discussion & Direction
For Clerk's Deot Use:
_ Consent Agenda
_ Public Hearing
_ Regular Agenda
X- Original Document/Contract Attached for Execution by City Clerk
Original Document/Contract Held by Department for Execution
(JA ~t/q
N/A
N/A
N/A
Reviewed by City Attorney
Reviewed by Finance Dept.
... R. d b Human Resou~
r eVlewe y Director M
City Manager
Robert Frank
Commissioners
Gary Hood. District 1
Scott Anderson. District 2
Rusty Johnson. District 3
Joel Keller. District 4
Mavor
S. Scott Vandergrift
STAFF REPORT
TO:
The Honorable Mayor and City Commissioners
Richard Firstner, Fire Chier @
August 5, 2008
FROM:
DATE:
RE:
Letter of Agreement
ISSUE
The City of Ocoee Fire Department seeks to enter into an agreement with Valencia Community College to
provide clinical instruction in the field of emergency medical services for students enrolled in the college
program. Students will ride along with seasoned Paramedic Firefighters of the Ocoee Fire Department and will
receive hands on instruction responding to emergency calls.
BACKGROUNDIDISCUSSION
Providing hands on training, in the field emergency medical services instruction is part of the established clinical
program requirements for certification, and is practiced by most agencies in the State of Florida.
The Ocoee Fire Department recommends that the City of Ocoee approve the agreement with Valencia
Community College to precept emergency medical service students. This agreement will allow the fire
department to preview potential candidates for employment, as well as market our department to the available
labor pool in the area.
1
~ CIA
Community College
July 2, 2008
Deputy Chief Pete McNeil
Ocoee Fire Department
563 S. Bluford Avenue
Ocoee, FL 34761
RE: LETTERS OF AGREEMENT
Dear Chief McNeil:
Thank you for your interest in providing Valencia Community College's EMS students
with supervised learning experiences at the Ocoee Fire Department. This is a standard
agreement and confidentiality statement (Exhibit A) that is designed to meet your HIP AA
related concerns. Valencia currently has in place agreements with approximately 60
clinical agencies in Orange and Osceola Counties. The terms of the contract are from
July 1, 2008 to December 31, 2010 with the option to renew for another two years.
We would very much appreciate a review of this Agreement. If you approve, please sign
all three sets and return all three sets to me. (A self addressed envelope has been
enclosed for your convenience.) An original executed copy will be forwarded to your
office upon completion of the signatures. A Certificate of Insurance will be ordered at
that time.
If you have any questions or concerns, please contact Darlene Powers, Office Supervisor
at 407/582-1537. Weare very grateful for the opportunity to work with your agency and
are thankful for your support.
Sincerely,
0~D~
Louise Pitts, EdD, ARNP, MSN
Dean of Health Sciences
Enclosures
1'.0 Box 3021\, OrlJlldo, FL 321\02-3028 . 407-2LJLJ5000, SUllcom 33LJ-Oll1
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AFFILA TION AGREEMENT
BETWEEN
THE DISTRICT BOARD OF TRUSTEES
OF
VALENCIA COMMUNITY COLLEGE, FLORIDA
AND
City of Ocoee, Florida
THIS AFFILIA TION AGREEMENT, entered into and effective July 1, 2008 is between THE
DISTRICT BOARD OF TRUSTEES OF VALENCIA COMMUNITY COLLEGE, FLORIDA,
(hereinafter the "College"), and City of Ocoee, Florida, (hereinafter the "Agency"), hereinafter collectively
referred to as the "Parties".
WHEREAS, the Agency is located at 150 N. Lakeshore Drive, Ocoee, Florida 34761 and provides clinical
and/or medical services and/or field experience;
WHEREAS, the College is a public higher educational institution with an approved program of study in
the field of EMS, which requires clinical experiences of students enrolled therein (hereinafter the
"Program" or "Clinical Program"), and desires its students in the Program (hereinafter the "Students" or
"Program Students") to obtain educational experiences by utilizing appropriate facilities within the Agency
(hereinafter the .'Facilities") and personnel of third parties consistent with the purpose of the College as
well as accreditation and/or professional requirements and standards;
WHEREAS, Agency is a municipal corporation which has the resources in equipment and staff to provide
the clinical experiences required by the EMS Program of the College, and has agreed to make such
resources available to College; and
WHEREAS, it is to the benefit of both the College and the Agency to cooperate in the educational
preparation of Students enrolled in the Program so as to promote excellence in patient care, to ensure
professional competence, and to provide maximum utilization of community resources;
NOW AND THEREFORE, in consideration of mutual promises herein and other good and valuable
consideration, College and Agency agree that any Program established and implemented by Agency and
College during the term of this Agreement shall be subject to the following terms and conditions:
1. PURPOSE. The purpose of this Agreement is to establish procedures and guidelines for the
provision of clinical experiences within the Facilities for Program Students.
2. RESPONSIBILITY OF AGENCY. Except for acts to be performed by College pursuant to the
provisions of this Agreement, Agency shall furnish the Facilities, personnel, services and all other
items necessary for the educational experience, and, in connection with such Program, Agency also
shall :
;1). Employ paramedic certified health care providers, administrative, and direct patient care staff
who are currently licensed to practice in their designated health profession, in the State and
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who are qualified either through experience and/or academically to uphold and demonstrate
standards of health care practice as established by Agency:
b). Cooperate with the College in enforcing College policies and procedures related to Student
performance and Student conduct.
c). Endeavor to comply with all applicable requirements of any accreditation authority over
Agency and College and certify such compliance upon request by College.
d). Permit the authority responsible for accreditation of College's curriculum to evaluate for
consistency with institutional purpose, vision, values and mission the Facilities, services and
all other items provided by Agency upon reasonable notice.
e). Designate a person to serve for Agency as liaison (hereinafter the "'Agency Liaison"), and
provide College, in writing, the name and professional and academic credentials of the
person proposed as Agency Liaison prior to the start of the educational experience(s), who
will:
(1 ) Assist the College's coordinating faculty members (hereinafter the "'Faculty") with
the planning of hospital clinical and field training learning experiences
(2) Meet with the College's coordinating Faculty to discuss the quality of the clinical
experiences and any problems which may have arisen in the provision of those experiences;.
f). Endeavor to include appropriate members of the Faculty in Agency staff meetings when
policies to be discussed will affect or are related to the Program and/or Students at the
Agency's discretion.
g). Provide the Students and Faculty with an orientation of the Facilities, or orientation packets
about the Facilities/Agency, which will include training about policies and procedures,
including without limitation the Health Insurance Portability and Accountability Act of 1996
(HIP AA), especially as it relates to the Agency's confidentiality requirements, and
instruction on OSHA regulations regarding blood-borne pathogens, infectious disease plans,
and hazardous chemical plan, and how, when and why to report incidents.
h). Provide supervised clinical experiences for Students that fulfill the curriculum requirements
of the Program and meet the objectives agreed upon by the College and the Agency. Allow
Faculty access to the Facilities for the purposes of coordinating, observing and instruction of
Students engaged in clinical experiences;
i). Plan, administer and retain total responsibility for all aspects of the emergency medical
services and provide supervision of all emergency medical services.
j). Provide faculty and Students with, or seek emergency accident care for injuries, or illnesses
of an acute nature, incurred while on duty at the Facilities. Emergency treatment of students
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for any injuries incurred during clinical activities must be covered through the student's
personal health insurance plan. or through hislher own resourc.es. Personal health insurance
coverage for the College's faculty and/or Students will not be the responsibility of the
College and/or Agency.
k). Not guarantee it will place or maintain placement of any Student at Agency.
I). Notify College, in writing, of any Student whose work or conduct with clients, patients or
personnel is not, in the opinion of Agency, in accordance with acceptable procedures or
standards of performance or otherwise could disrupt patient care or Agency's operation. The
written notice shall contain a sufficiently detailed description of the work or conduct
necessitating the notice or removal of the Student from the Facilities, within five (5)
business days of the occurrence of the work or conduct in issue. Agency may immediately
remove from the premises any Student who poses an immediate threat or danger to
personnel or to the quality of medical services, or for unprofessional behavior. In such event,
said Student's participation in the Program at Agency shall immediately cease, subject to
being resumed only with the mutual written agreement of Agency and College.
m). Orient Agency staff to the curriculum and encourage an atmosphere conducive to learning;
n). Provide Faculty with written policies, procedures, standards of care and protocols of Agency,
which College acknowledges shall govern Students and Faculty involved in the Clinical
Program. The Agency may at any time summarily relieve a Student from a specific assignment,
or request that a Student or Faculty member leave a patient care area for causes related to the
quality of patient care;
0). Maintain its operating license and appropriate accreditation.
3. RESPONSIBILITIES OF COLLEGE. The College shall:
a). Require a physical examination of all Students prior to their participation in the Program.
This examination shall include general physical exam, utilizing history (mobility, motor
skills, hearing, visual and tactile abilities) and immunization assessment (Rubella, Rubeloa,
Varicella, Diphtheria, Hepatitis B) TB screening, and Tetanus.
b). Provide Agency, in writing, the names of the Students assigned by College to participate in
the Program prior to the beginning ofthe Program's educational experience(s).
c). Present Program Students for clinical experiences who have adequate preclinical instruction
and who, in the discretion of the Faculty, have adequately fulfilled the preclinical
requirements of the Program curriculum;
d). Agree to require Students to obtain and maintain, as a condition of their participation in the
Program, and during the term of their Program participation at Agency, professional liability
insurance. Such insurance shall be on a per occurrence basis in amounts no less than one
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million dollars/three million dollars ($ I .000.000.00/$3.000.000.00) for personal injuries.
Prior to any Student commencing his or her training. the College shall provide the Agency
with a Certificate of Insurance evidencing such coverage. Such professional liability
insurance shall cover any and all liability for claims, damages. or injuries to persons
whatsoever kind or nature arising out of the activities of such Student carried out under this
Agreement. Agency shall be named as a loss payee insured under such professional liability
policy or policies.
e). Provide the services of a Faculty member, or other College liaison, who will:
(1) Plan, in conjunction with staffmember(s) of the Agency, the clinical experiences and
patient care assignments that will fulfill the clinical requirements of the Program
curriculum: and
(2) Meet with staff member(s) of the Agency to discuss the quality of the clinical
experiences and any problems which may have arisen in the provision of those
expenences.
f). Upon receipt of Agency's written notice of a Student or other Program participant whose
work or conduct with clients, patients or personnel is not in accordance with acceptable
procedures or standards of performance or otherwise could disrupt patient care or Agency's
operation, evaluate such Student's or Program participant's conduct and take appropriate
action. It is understood that, if Agency takes action under the provisions of Section 2.1.,
above, that the Student's or Program participant's participation in the Program at Agency
shall immediately cease, subject to being resumed only with the mutual written agreement of
College and Agency.
g). Not guarantee it will place or maintain the placement of any Program Student at Agency.
h). Agree to require participating Faculty, staff and Students to comply with the applicable
policies and procedures of the Agency during the course of their participation, to the extent
permitted by law and, in so far as they do not conflict with any of the College's policies and
procedures, including those governing the use and disclosure of individually identifiable
health information under Federal law and regulations, including but not limited to
regulations under the Health Insurance Portability and Accountability Act ("HIP AA").
Solely for the purpose of defining the Students' role in relation to the use and disclosure of
the Agency's protected health information, such Students are defined as members of the
Agency's workforce, as that term is defined by 45 CFR 160.103, when engaged in activities
pursuant to this Agreement. However, such Students are not and shall not be considered to
be employees ofthe Agency.
i). Agree to require Program Students, Faculty and other College-employed Program
participants, as a condition of their participation in the Program, to execute a Confidentiality
Statement [(Exhibit A) or in another form mutually accepted by the Parties] with the
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Agency, acknowledging their responsibility under applicable Federal law and regulations,
including but not limited to regulations under the Health Insurance Portability and
Accountability Act ("HIP AA "), to keep confidential any information regarding Agency
patients, as welJ as confidential infonnation of the Agency.
j). Maintain individual records of class and clinical instruction. evaluations of Students.
preceptor, and Faculty competency and health.
k). Establish and maintain for this clinical Program, curriculum standards and educational policies
that meet College standards and applicable licensing and accreditation requirements;
I.) Administer, organize and operate the overall clinical educational Program and retain
responsibility for the education of Students in and for the Program curriculum, its design,
delivery, and quality;
m). Provide course outlines to Agency that include objectives, goals and classes for each course
providing clinical experience;
n). Provide Agency with a copy of the College's Student Code of Conduct Policy and/or the
Health Science Program's Student Handbook that sets forth the rules governing student
behavior.
4. RESPONSIBILITY TO INFORM STUDENTS. The College shall inform its Students in the
Program that as participants in the Program they are required to:
a). Comply with the policies and procedures of Agency, to the extent permitted by law and, in
so far as they do not conflict with any of the College's policies and procedures, including the
Agency's policies on confidentiality and disclosure of information;
b). Comply with state and federal laws and regulations;
c). Provide and wear the necessary and appropriate uniform while on duty at Agency;
d). Obtain prior written approval of the Parties before publishing any material related to the
learning experience provided under the terms of this Agreement.
c). Maintain the confidentiality of all records or information exchanged in the course of the
Program. -
f). Acknowledge and agree that neither the College nor the Agency guarantees to place or
maintain placement of any Program Student under this Agreement.
g). Obtain and document, at the Student's sole expense, such trustworthy and verifiable
criminal background and/or health or other information as Agency requests or requires as a
prerequisite to Agency's considering Student for placement at Agency. Upon College's
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request Student shall also submit the above-referenced criminal and/or health or other
information to the College.
h). Execute and abide by the Confidentiality Statement (Exhibit A) pursuant to Section 2(i)
above.
i). Procure and maintain, during the term of their Program participation at Agency. professional
liability insurance. Such professional liability insurance shall cover any and all liability for
claims, damages, or injuries to persons whatsoever kind or nature arising out of the activities
of such Student carried out under this Agreement. Such professional liability insurance shall
be on a per occurrence basis in amounts no less than one million dollars/three million dollars
($1,000,000.00/$3,000,000.00) for personal injuries. Agency shall be named as a loss payee
under such professional liability policy or policies. College shall submit to Agency
certificates of insurance evidencing such insurance at the time Student's Program
participation at Agency is to begin. IOn the event Program Students participating at Agency
will not have patient contact, those Students shall not be required to procure and maintain
any such policy or policies ofliability insurance as described above.
5. RESPONSIBILITY OF THE COLLEGE AND THE AGENCY: PROGRAM
COORDINATION.
a). College and Agency agree to work together to establish and maintain a quality Clinical
Program. Agency agrees to take an active role in suggesting or establishing education policy,
curriculum, and course content.
b). College and Agency agree to provide representatives to form a Liaison Committee to meet
periodically to fashion, discuss, evaluate, and make recommendations to revise the Clinical
Program experience at Agency. College agrees upon request to provide representatives from
the Faculty to serve on Agency committee(s) relevant to the Clinical Program.
c). The parties acknowledge that many student educational records are protected by the Family
Educational Rights and Privacy Act ("FERP A"), and that student permission must be obtained
before releasing specific student data to anyone other than College. College agrees to provide
guidance to Agency with respect to complying with FERP A. Agency agrees to treat all student
records confidentially and not to disclose student records except to College and Agency
officials who have a legitimate need to know consistent with their official responsibilities.
d). Neither party shall have the power to obligate the other party's resources, or commit the other
party to any particular action.
e). Both Parties and their employees shall conduct themselves in compliance with all applicable
federal, state, and local laws, rules, and regulations and in compliance with the standards,
rulings, and regulations of the Joint Commission on Accreditation of Health Care
Organizations, the Department of Health and Human Services, and the State Department of
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Health and Rehabilitative Services, as well as their own respective institutional rules and
regulations.
f). The College and the Agency agree that, in the event that either becomes aware of a claim
asserted by any person arising out of this Agreement or any activity carried out under this
Agreement, the Parties shall cooperate in securing evidence and obtaining the cooperation of
witnesses.
6. REQUEST FOR WITHDRAWAL OF STUDENT. College shall have full responsibility for
the conduct of any Student disciplinary proceedings and shall conduct the same, with input from
Agency, in accordance with all applicable statutes, rules, regulations and case law.
(a) No provision of this Agreement shall prevent Agency from refusing to accept or continue
any Student in the Program who has previously been discharged for cause as an employee of
the Agency, who has been removed from or relieved of responsibilities for cause by the
Agency or for other good cause. The Agency shall notify the College in writing of its refusal
to accept or continue a Student and the basis therefore. In an emergency, Agency can
impose temporary withdrawal of a Student. The Agency shall provide to the College prompt
written notice of such a withdrawal, which shall state the reason(s) for the temporary
withdrawal.
(b) The Agency may also submit a written request to College for the permanent withdrawal of
any Student from the Program for a reasonable cause related to the need for maintaining a
safe and orderly environment, and the College shall immediately comply with such request.
The written request from the Agency shall set forth the basis for withdrawal.
(c) In the event the College does not agree with the Agency's refusal to accept or continue a
Student, its temporary withdrawal of a Student, or its request for permanent withdrawal of a
Student, it shall promptly (in any event not later than five working days after receipt of the
written notice or request from the Agency) provide the Agency with a written statement
setting forth the basis for any such disagreement.
(d) To the extent permitted by law, the Agency will defend, indemnify and hold the College
harmless from any and all claims and costs arising from the Agency's refusal to accept,
temporary withdrawal of, or request for the withdrawal of any Student, if the College has
provided its timely written statement of disagreement, provided that the Agency is
determined by any court or administrative agency of competent jurisdiction to have acted in
an unlawful manner in refusing to accept, requiring the temporary withdrawal of, or
requesting the withdrawal of a Student; and further provided that the College shall promptly
notify the Agency of any such claim, provide the Agency with an opportunity to defend,
and provide the Agency with all reasonable assistance, except financial, in making such
defense. No settlement of any such claim as it relates to the Agency shall be effected
without the consent of the Agency. The foregoing shall not be construed as a waiver of the
Agency's commitments.
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(e) The College may at any time withdraw a Student whose progress, conduct or work does not
meet the standards of the College for continuation in the Program. Final action concerning
the Student is the responsibility ofthe College.
7. INDEPENDENT CONTRACTOR/STUDENT STATUS. The relationship of the Parties
hereunder shall be an independent contractor relationship, and not an agency. employment. joint
venture or partnership relationship. Neither party shall have the power to bind the other party or
contract in the name of the other party. All persons employed by a party in connection with this
Agreement shall be considered employees of that party and shall in no way, either directly or
indirectly, be considered employees or agents of the other party.
Students shall participate in the Program hereunder for the sole consideration of obtaining an
educational experience. Each party agrees that the Students will be in a learning situation and that
the primary purpose of the placement is for the Students' learning. It is further understood that the
Student shall not at any time replace or substitute for any Agency employee. Nor shall Student
perform any of the duties normally performed by an employee of the Agency except such duties as
are a part of their training and are performed by the Student under the direct supervision of a
Facility employee. Each party agrees that no Student in the Program(s) will be deemed to be an
employee or volunteer of the Agency nor of the College, nor will the Agency or the College be
liable for the payment of any wage, salary, or compensation of any kind for service provided by the
Students. Further, no Student will be covered under the Agency's or the College's Worker's
Compensation, social security, or unemployment compensation programs.
8. INSURANCE.
a) INSURANCE OF COLLEGE. The Agency acknowledges that the College is a
political subdivision of the State of Florida and warrants, and represents that it participates
in the Florida Community College Risk Management Consortium, with headquarters in
Gainesville, Florida, for worker's compensation, general liability, and other coverage, with
said protection being applicable to officers, employees, servants, and agents while acting
within the scope of their employment by the College. Its self insured fund and various
policies are authorized and stated in Florida Statutes, Section 1001.64(27) and Section
768.28. The College agrees to maintain its participation in the Florida Community College
Risk Management Consortium for the duration of this Agreement. Furthermore, nothing
contained herein shall be construed or interpreted as: (i) denying to either party any remedy
or defense available to such party under the laws of the State of Florida; (ii) the consent of
the College to be sued; or (iii) a waiver of sovereign immunity of the College beyond the
waiver provided in Section 768.28, Florida Statutes..
b) INSURANCE OF AGENCY. Agency shall maintain, at its own cost and expense,
general and professional liability insurance covering Agency as an entity and each of its
health care providers against professional liability (malpractice) claims, in the minimum
amount of One million dollars ($ 1,000,000) per occurrence and Three million dollars ($
3.000.000) aggregate. Evidence of such insurance shall be provided to College upon
request.
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9. ASSIGNMENTS. This Agreement may not be assigned to a third party without the prior written
consent of the non-assigning party.
10. THIRD PARTY OBLIGATIONS. This Agreement is made solely for the benefit of the Parties
named in this Agreement, and is not intended to create rights or any cause of action in any third
parties, including without limitation, Students.
11. PERFORMANCE. A delay in or failure of performance of either party that is caused by
occurrences beyond the control of either party shall not constitute a default hereunder. or give rise
to any claim for damages.
12. TERM AND TERMINATION. The term of this Agreement is July 1. 2008 through December
31. 2010 (the "Term"). This Agreement may be extended or renewed upon advanced written
agreement of the Parties hereto.
If either party to this Agreement wishes to terminate the Agreement, it is understood that at least
ninety (90) days prior written notice shall be given prior to the termination date of the Agreement.
And, if such notice is given, this Agreement shall terminate at the end of the ninety (90) days'
notice; EXCEPT THAT the Program shall continue as necessary on a limited basis for the purpose
of permitting Students actually participating in the Program at the time of termination to finish the
Program at Agency.
13. APPLICABLE LAW. The validity, interpretation and enforcement of this Agreement shall be
governed by the laws of the State of Florida.
14. NONDISCRIMINATION. During this Agreement. neither party shall discriminate against any
person on the basis of race, color, religion, gender, national or ethnic origin, sexual orientation,
disability or veteran or marital status.
15. ENTIRETY OF AGREEMENT. This Agreement contains the entire Agreement between the
Parties and supersedes all prior agreements and understandings, oral or written, with respect to the
subject matter contained herein.
16. AMENDMENTS AND MODIFICATIONS TO AGREEMENT. All amendments and
modifications to this Agreement shall be made by addenda and with the written mutual consent of
both Parties. The addenda shall be attached to the Agreement, and shall include the date and
signatures of Parties agreeing to the modification(s).
17. COPIES OF AGREEMENT. Copies of this Agreement shall be placed on file and be
available at the College and at the Agency.
18. NOTICES. All notices under this Agreement shall be in writing and delivered by personal
delivery or United States, certified, return receipt requested, mail. Such notices shall be delivered to
the following:
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AGENCY LIAISON:
COLLEGE REPRESENTATIVE:
Pete McNeil, Deputy Chief
Ocoee Fire Department
563 S. Bluford Ave
Ocoee, FL 34761
407/905-3] 40
Louise Pius, Dean
Valencia Community College
P.O. Box 3028, Mail Code 4-]4
Orlando, FL 32802-3028
407/582-] 537
APPROVED:
COLLEGE
By:
Keith Houck Date
Vice President for Administrative Services
AGENCY
ATTEST:
CITY OF OCOEE, FLORIDA
By:
Beth Eikenberry, City Clerk
S. Scott Vandergrift, Mayor
FOR USE AND RELIANCE ONLY BY
THE CITY OF OCOEE, FLORIDA:
APPROVED AS TO FORUM AND
LEGALITY this _ day of
, 2008.
APPROVED BY THE OCOEE CITY
COMMISSION AT A MEETING
HELD ON , 2008
UNDER AGENDA ITEM NO.
FOLEY & LARDER LLP
By:
City Attorney
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(EXHIBIT A)
CONFIDENTIALITY STATEMENT
School:
Program:
Facility/ Agency:
The undersigned hereby acknowledges his/her responsibility under applicable federal law and regulations,
including but not limited to regulations under the Health Insurance Portability and Accountability Act
("HIP AA"), to keep confidential any information regarding Facility/Agency patients, as well as all
confidential information of Facility/Agency. The undersigned agrees, under penalty oflaw, not to reveal to
any person or persons any specific information regarding any patient, except to authorized clinical staff and
associated personnel of the Facility/Agency and, as necessary, to other Program Participants/Students at the
Facility/Agency who are supervising or assisting the undersigned in the provision of services at
Facility/Agency. The undersigned further agrees not to reveal to any third party any confidential
information of Facility/ Agency, except as required by law or as authorized by Facility/Agency.
day of
,20_
Dated this
Program Participant/Student
Print Name
Witness
Print Name
II