HomeMy WebLinkAboutItem #07 Approval of Renewal of EMT/PAramedic Student Affliation Agreement between the City of Ocoee and Valencia College Ocoee
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AGENDA ITEM COVER SHEET
Meeting Date: October 20, 2015
Item #
Reviewed By:
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Contact Name: John Miller, Fire Chief Department Director: John ;''II=
Contact Number: 407 - 905 -3140 City Manager: Robert Fr- ; /
Subject: Renewal of EMT /Paramedic Student Affiliation Agreement between the City of Ocoee
and Valencia College.
Background Summary:
The City Commission originally approved for the Ocoee Fire Department to enter into an agreement with
Valencia College to provide supervised learning experiences for the college's emergency medical services
students on August 5, 2008. That agreement was approved for renewal on November 2, 2010 and again on
November 19, 2013. The current agreement is set to expire on December 31, 2015. The Ocoee Fire Department
would like to renew the agreement for another two year period from January 1, 2016 to December 31, 2017.
Issue:
The City of Ocoee Fire Department utilizes its facilities to provide clinical experiences for students enrolled in
the college's emergency medical services programs. This provides an excellent learning experience for both the
students and the personnel of the Ocoee Fire Department. The terms of the original agreement allow it to be
extended by agreement of both parties. Commission approval is requested for the new agreement.
Recommendations
It is the recommendation of the Ocoee Fire Department that the City of Ocoee adopt the January 1, 2016 to
December 31, 2017 agreement between the City of Ocoee and Valencia College.
Attachments:
Two sets of the agreement to be signed and returned to Valencia College.
Financial Impact:
There is no financial impact to either party.
Type of Item: (please mark with an `x')
Public Hearing For Clerk's Dept Use:
Ordinance First Reading ), Consent Agenda
Ordinance Second Reading Public Hearing
Resolution Regular Agenda
Commission Approval
Discussion & Direction
Original Document/Contract Attached for Execution by City Clerk
Original Document/Contract Held by Department for Execution
Reviewed by City Attorney N/A
Reviewed by Finance Dept. N/A
Reviewed by 0 N/A
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AFFILIATION AGREEMENT
BETWEEN
THE DISTRICT BOARD OF TRUSTEES
OF
VALENCIA COLLEGE, FLORIDA
AND
THE CITY OF OCOEE, FLORIDA
THIS AFFILIATION AGREEMENT, entered into and effective January 1 , 2016,
is between THE DISTRICT BOARD OF TRUSTEES OF VALENCIA COLLEGE,
FLORIDA, (hereinafter the "College "), and THE 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;
WHEREAS, the College is a public higher educational institution with approved
programs of study as specified in Exhibit "A," (hereinafter the "Programs "), which require
clinical or observation experiences of students enrolled therein (hereinafter "Clinical or
Observation Experience Rotation" or "Rotation "), and desires its students in the Programs
(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; and
WHEREAS, Agency is a municipal corporation which has the resources in equipment
and staff to provide the educational experiences required by the Programs, 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 Programs 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 Rotation 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 educational 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 Rotation, Agency also shall:
a). Employ medical/health care providers, administrative, and direct patient care staff
who are currently licensed to practice in their designated health profession in the
State and 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 a mutually agreeable manner in enforcing College
policies and procedures related to Student performance and Student conduct,
provided that such policies and procedures do not conflict with Agency's policies
and procedures. In the event of a conflict, Agency's policies and procedures will
control.
c). Endeavor to comply with all applicable requirements of any accreditation
authority over Agency 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(s) to serve for Agency as liaison(s) (hereinafter the "Agency
Liaison "), and provide College, in writing, the name and professional and
academic credentials of all persons 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 educational experiences and patient care
assignments; and
(2) Meet with the College's coordinating Faculty to discuss the quality of the
educational experiences and any problems which may have arisen in the
provision of those experiences.
O. Endeavor to include appropriate members of the Faculty in Agency meetings or
communications when policies to be discussed will affect or are related to the
Rotation 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 (HIPAA), as modified by the Health
Information and Technology for Economic and Clinical Health Act (HITECH
Act), especially as it relates to the Agency's confidentiality requirements, and
instruction on OSHA regulations regarding blood -borne pathogens, infectious
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r .
disease plans, and hazardous chemical plan, and how, when and why to report
incidents.
h). Provide supervised educational 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 educational
experiences;
i). Plan, administer and retain total responsibility for all aspects of patient care and
provide for qualified supervision of all patient activities.
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 or Faculty for any injuries incurred during
educational activities must be covered through the individual's personal health
insurance plan, or through his /her own resources. 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.
1). Notify College 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 notice shall be prompt and contain an appropriate
description of the work or conduct necessitating the notice or removal of the
Student from the Facilities. Agency may withdraw any Student or Faculty from its
facilities whose conduct or work with patients, personnel, or medical staff is not
in accordance with the policies and procedures of Agency or is detrimental to
patients or others and College agrees to immediately communicate and implement
as appropriate the Agency's determination to withdraw such student or instructor
from Agency's Facilities.
m). Provide Faculty with written policies, procedures, standards of care and protocols of
Agency, which College acknowledges shall govern Students and Faculty involved in
the Rotation. 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;
n). Maintain its operating license and appropriate accreditation.
o). Provide preceptors for any Rotation for which College requests preceptors.
Preceptors selected by Agency for a Rotation will meet such experience, licensure,
and skills requirements as are mutually agreed upon by the College and the
Agency. Agency designee will work with Faculty in determining the assignment
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of Agency preceptors within the Rotation(s). The Program(s) for which Rotation
preceptors are requested are listed on Exhibit "B ".
3. RESPONSIBILITIES OF COLLEGE. The College shall:
a). Require a physical examination of all Students prior to their participation in the
Rotation. The physical examination shall include general physical exam, utilizing
history (mobility, motor skills, hearing, visual and tactile abilities) and
immunization assessment and any other exam that Hospital may reasonably
require. Students and Faculty must have current immunizations including
Varicella, Hepatitis B (or signed waiver if refused), MMR, Tetanus. If titer is
negative for Varicella, College will require Student to receive Varicella vaccine.
If Student has positive PPD results, College will provide confirmation that
Student has a negative chest x -ray. All Students and Faculty must have a current
(within one year) PPD. College will notify Hospital of any positive PPD results.
College will require any Student who may be exposed to a patient with known or
suspected TB to be fitted for a respirator. College will maintain required
immunization records.
b). Provide verification consistent with the requirements of this section indicating that
a criminal background check has been conducted on all Students 18 years of age
or older and all Faculty, prior to commencement of a Rotation. The criminal
background check must include all cities, counties, and states in which the Student
or Faculty has resided and in which the Student or Faculty has worked at any time
during the preceding ten (10) years. Agency will provide College with a list of
convictions and /or pending charges that Agency has determined will disqualify a
Student or Faculty from Rotation participation ( "Student Disqualification
Guidelines — Criminal Background" attached hereto as Exhibit C), which College
will use in connection with background checks. College will not send any Student
or Faculty who is clearly disqualified to Agency's facility to participate in a
Rotation. In the event College is unable to determine whether a particular Student
or Faculty is disqualified pursuant to Agency's list, College will consult Agency
for Agency's evaluation and determination. Agency retains the ultimate right to
determine if a Student is disqualified.
c). Provide Agency, in writing, the names of the Students assigned by College to
participate in the Rotation prior to the beginning of the Rotation.
d). Present Program Students for Rotations who have adequate preclinical instruction
and who, in the discretion of the Faculty, have adequately fulfilled the preclinical
requirements of the Program curriculum;
e). Procure and maintain, through the Florida College System Risk Management
Consortium (FCSRMC), occurrence -type professional liability insurance
coverage in amounts not less than one million dollars ($1,000,000.00) per incident
and three million dollars ($3,000,000.00) annual aggregate covering the Students
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and any Faculty members for instruction/supervision of Students only. At the
Agency's request, the College shall provide the Agency with a Certificate of
Insurance evidencing such coverage.
f). Provide the services of a Faculty member, or other College liaison, who will:
(1) Plan, in conjunction with staff member(s) of the Agency, the educational
experiences and patient care assignments that will fulfill the educational
requirements of the Program curriculum; and
(2) Meet with staff member(s) of the Agency to discuss the quality of the
educational experiences and any problems which may have arisen in the
provision of those experiences.
g). Upon receipt of Agency's notice of a Student or other Rotation 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 Rotation
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
Rotation participant's participation in the Rotation at Agency shall immediately
cease, subject to being resumed only with the mutual written agreement of
College and Agency.
h). Not guarantee it will place or maintain the placement of any Program Student at
Agency.
i). 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. 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 of the Agency or of College.
j). 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 D) or in another form mutually accepted by
the Parties] with the Agency, acknowledging their responsibility under applicable
Federal law and regulations, including but not limited to regulations under the
Health Insurance Portability and Accountability Act ( "HIPAA "), to keep
confidential any information regarding Agency patients, as well as confidential
information of the Agency, as a condition of participation in the Rotation; and
provide Agency with copies of the executed Confidentiality Statements for each
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Program Student, Faculty, and other College - employed Rotation Participant prior
to the start of the Rotation.
k). Maintain individual records of class and clinical instruction, evaluations of
Students, preceptor, and Faculty competency and health.
1). Establish and maintain for this educational Rotation, curriculum standards and
educational policies that meet College standards and applicable licensing and
accreditation requirements;
m.) Administer, organize and operate the overall educational Program and retain
responsibility for the education of Students in and for the Program curriculum, its
design, delivery, and quality;
n). Provide course outlines to Agency that include objectives, goals and classes for each
course providing educational experience;
o). 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 Rotation they are required to:
a). Comply with the policies and procedures of Agency, to the extent permitted by
law, 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 both Parties before publishing any material
related to the learning experience provided under the terms of this Agreement.
e). Maintain the confidentiality of all records or information exchanged in the course
of the Rotation.
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). As required by Agency as a condition of participation in the Rotation, execute and
abide by the attached Confidentiality Statement (Exhibit D) pursuant to Section
2(i) and 3(j) above.
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5. RESPONSIBILITY OF THE COLLEGE AND THE AGENCY: ROTATION
COORDINATION.
a). College and Agency agree to work together to establish and maintain a quality
Rotation. 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 an Advisory
Committee to meet periodically to fashion, discuss, evaluate, and make
recommendations to revise the Rotation experience at Agency. College agrees upon
request to provide representatives from the Faculty to serve on Agency committee(s)
relevant to the Rotation.
c). The parties acknowledge that many student education records are protected by the
Family Educational Rights and Privacy Act ( "FERPA "), [20 United States Code
sections 1232(g), 1232(h) and 1232(i)], and federal regulations issued pursuant to
such act, and by state law in s. 1002.22, F.S., and that generally, written student
consent must be obtained before releasing personally identifiable student education
records to anyone other than College. College agrees to provide guidance to Agency
with respect to complying with the provisions of FERPA and similar state law.
Agency agrees to treat all student education records that are specifically identified as
such by the parties confidentially and not to disclose such student education records
except to College and Agency officials who need the information to fulfill their
professional responsibilities, or as required or permitted by law. The parties
acknowledge that the fact that a Student is mentioned in a record or report generated
and/or maintained by Agency in the normal course and scope of its operations, and
not created or maintained by College, may not cause such record or report to be
considered a "student education record" for purposes of this paragraph.
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 relevant accreditation and regulatory
bodies, as well as their own respective institutional rules and regulations.
f). A Party will cooperate fully with the other Party and its counsel in the defense of
any claims against a Party in any way arising out of or connected with this
Agreement. Such cooperation, including attendance at depositions, trials,
conferences, and the rendering of written reports, will be at no expense to the
Party subject to the claim.
6. REQUEST FOR WITHDRAWAL OF FACULTY OR STUDENT. College shall
have full responsibility for the conduct of any Student or Faculty disciplinary proceedings
and shall conduct the same, with input from Agency, in accordance with all applicable
statutes, rules, regulations and case law.
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(a) No provision of this Agreement shall prevent Agency from refusing to accept or
continue any Student or Faculty in the Rotation at Agency's Facilities who has
previously been employed by Agency and who has been determined by Agency to
be ineligible for rehire for any reason. The Agency shall notify the College in
writing of its refusal to accept or continue a Student or Faculty in the Rotation on
this basis but shall be under no obligation to provide a reason any individual is
considered ineligible for rehire. Agency can impose temporary withdrawal of a
Student or Faculty from Agency's Facilities. 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 to College a notice documenting its decision to
require the permanent withdrawal of any Student or Faculty from Agency's
Facilities for a reasonable cause related to the need for maintaining a safe and
orderly environment, and the College shall immediately cause the Student or
Faculty to comply with Agency's decision as documented. The notice 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 or Faculty, Agency's temporary withdrawal of a Student or
Faculty from Agency's facilities, or Agency's request for permanent withdrawal
of a Student or Faculty from Agency's facilities, the College may request a
meeting with the Agency's designee to discuss the basis for any such
disagreement, which meeting will be scheduled within a reasonable time as
mutually agreed between the parties. The parties agree that if such a meeting is
requested, the Student or Faculty in question will not be permitted in Agency's
Facilities pending the outcome of the meeting. Agency's decision following such
meeting will be final.
(d) The College may at any time withdraw a Faculty member or Student whose
progress, conduct, or work does not meet the standards of the College for
continuation in the Program.
7. INDEPENDENT CONTRACTOR/STUDENT STATUS.
a). 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 not be considered employees of either party notwithstanding
the language of Section 3(i) herein. In no circumstance shall Students be
considered employees or agents of College, and College shall not be responsible
for the actions or omissions of Students.
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b). Students shall participate in the Rotation 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 and the benefit of the Students. 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 an Agency employee. Students are not
entitled to a job at the completion of the educational experience. Agency derives
no immediate advantage from the activities of the Students, and on occasion its
operations may actually be impeded. The Agency, College and the Students
understand that the Students are not entitled to wages for the time spent in
training. Each party agrees that no Student in the Rotation will be deemed to be an
employee, agent or volunteer of the Agency or the College by virtue of
participation in the Rotation, 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 while participating in the Rotation. Further, no Student will be
covered under the Agency's or the College's Worker's Compensation, social
security, or unemployment compensation programs while participating in the
Rotation.
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, through commercial insurance, a program of self - insurance, or a
combination thereof, general and professional liability insurance covering Agency
against professional liability (malpractice) claims, in the minimum amount of
Two Hundred Fifty Thousand dollars ($250,000) per occurrence/ Seven Hundred
Fifty Thousand dollars $750,000) aggregate for facility malpractice and Five
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Hundred Thousand dollars ($500,000) per occurrence /One Million Five Hundred
Thousand dollars ($1,500,000) aggregate for medical director malpractice.
Evidence of such insurance or self - insurance shall be provided to College upon
request.
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 January 1, 2016
through December 31, 2017 (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 Rotation and this Agreement shall
continue to be effective for the purpose of permitting Students actually participating in
the Rotation at the time of termination to finish the Rotation 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.
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18. NOTICES. All notices under this Agreement shall be in writing and delivered by
personal delivery of United States, certified, return receipt requested, mail. Such notices
shall be delivered to the following:
College Representative: Penny Conners, Dean
Valencia College
P.O. Box 3028
Mail Code 4 -44
Orlando, Florida 32802 -3028
407/582 -1537 pconnersl @valenciacollege.edu
Agency Representative: John Miller, Fire Chief
Ocoee Fire Department
563 S. Buford Avenue
Ocoee, FL 34761
407/905 -3140 Jmiller @ocoee.org
APPROVED:
VALENCIA COLLEGE
Loren J. Bender
Vice President, Operations & Finance
Date:
AGENCY
ATTEST: CITY OF OCOEE, FLORIDA
By:
Beth Eikenberry, City Clerk S. Scott Vandergrift, Mayor
FOR USE AND RELIANCE ONLY BY APPROVED BY THE OCOEE
THE CITY OF OCOEE, FLORIDA: COMMISSION AT A MEETING
APPROVED AS TO FORM AND HELD ON , 2015
LEGALITY THIS day of UNDER AGENDA ITEM NO.
, 2015
FOLEY & LARDNER, LLP By:
City Attorney
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EXHIBIT A
The Programs
Emergency Medical Services
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EXHIBIT B
Programs for Which Preceptors are Requested
Emergency Medical Services
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EXHIBIT C
Student Disqualification Guidelines — Criminal Background
A student will be disqualified from placement at any Agency facility if the student admits to, or a
criminal background check reveals, a conviction or any disposition other than a finding of "not
guilty" or a complete dismissal of the charges for one or more of the following generic crimes or
their equivalents:
Murder
Manslaughter
Carjacking
Use of a weapon in the commission of a crime
Robbery or theft (including, but not limited to, theft by falsification of financial records or
embezzlement)
Passing worthless checks
Credit card fraud /fraudulent use of a credit card
Forgery
Identity theft
Burglary
Arson
Kidnapping
False Imprisonment
Home invasion
Assault
Aggravated assault
Battery
Aggravated battery
Resisting arrest with violence
Domestic violence
Any stalking offense
Rape
Sexual battery
Trespass for sexual purposes (e.g., peeping)
Lewd and lascivious behavior
Lewd and lascivious act upon a child
Lewd act in the presence of a child
Child abuse
Child abandonment
Child neglect
Any other crime involving physical violence or a crime against a child
Possession of child pornography
Sale, delivery or trafficking in child pornography
Exploitation, neglect, or abuse of a disabled adult or elderly person
Sale, delivery or trafficking in narcotics (drugs)
Felony possession of a controlled substance
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Any other felony level offense involving violation of a drug abuse prevention and control law
(including but not limited to felony level possession, sale, purchase, manufacture, or use of
controlled substance in violation of applicable law)
Felony driving while intoxicated or under the influence of drugs or alcohol
Falsification of prescription records
Hate crimes
Terrorism
Escape or attempted escape from incarceration
A student who admits to, or whose criminal background check reveals, a criminal conviction or
any disposition other than a finding of "not guilty" or a complete dismissal of the charges
relating to crimes other than those listed above is not automatically disqualified and may be
considered for placement at an Agency facility based on a case -by -case evaluation, including ,
but not limited to, the following factors: nature of the offense(s); criminal history
(pattern/recidivism); remoteness in time of the offense; relevance of offense to position being
offered; age at time of offense; and evidence of rehabilitation.
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(EXHIBIT D)
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 ( "HIPAA "), to keep confidential any information regarding Facility /Agency
patients, as well as all confidential information of Facility /Agency. The undersigned agrees,
under penalty of law, 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.
Dated this day of , 20
Program Participant /Student (Signature)
Program Participant /Student (Printed Name)
Witness (Signature)
Witness (Printed Name)
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