continue+sccp+forms

** CLINICAL EXPERIENCES TRAINING AGREEMENT  ** Student’s Name _______________________________________ Birth Date ____________ Age Student’s Address _ Telephone ____________________ Cell Phone _________________ E-mail Current Career Objective/Pathway _______________________ Job Title School Name ________________________________________ System Clinical Learning Site __________________________________ Telephone Clinical Site Address Health Science Instructor ____________________________ Mentor Date Training Period Begins ______________________________ Ends This training agreement briefly outlines the responsibilities of the student, parents, Clinical Mentor employed by the participating Healthcare Agency, and the Health Science instructor. The second part of this document is entitled “Training Plan” and consists of tasks and competencies for the specific student’s career objective/pathway. // The school or training agency may remove a student upon 30 days written notice or immediately with cause. //  **  Parent/Guardian  **  1. Approves and agrees that the student may participate in the Clinical Experience.  2. Encourages the student to effectively carry out the requirements and all components of the program.  3. Assumes responsibility for the conduct and attendance of the student.  4. Provides transportation for the student to and from the Clinical Experience site.  5. Holds the school, Health Science Instructor and training agency harmless for risks associated with transportation and indirectly monitored activities (e.g., Clinical Experience). ** Student  **  1. Complies with the rules and regulations of the Clinical Experience site.  2. Adheres to all policies and regulations as set forth by school administration and the Health Science instructor.  3. Shall, at the student’s expense, take required physical examinations or TB tests as required by the program and/or the Clinical Experience site.  4. Shall have and maintain liability insurance coverage while participating in the Clinical Experience.  5. Is an active member of the student organization, HOSA.  6. Participates for the number of hours required for the Clinical Experience.  7. Shall not perform duties in which he/she has not received instruction.  8. Shall keep regular attendance at school and at the clinical training site.  9. Any student failing to comply with policies, rules and regulations is subject to dismissal from the program.  10. Shall be responsible for transportation to and from the Clinical Experience site.  11. Shall not displace adult workers who can perform such work as assigned in the work-based experience. ** Health Science Instructor  ** <span style="margin: 0in -19.8pt 0pt 0.75in; mso-list: l3 level1 lfo3; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 1. Secures appropriate Clinical Experiences based on the student’s career objective/pathway. <span style="margin: 0in -19.8pt 0pt 0.75in; mso-list: l3 level1 lfo3; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 2. Works with the Clinical Mentor in developing Training Plan for the student. <span style="margin: 0in -19.8pt 0pt 0.75in; mso-list: l3 level1 lfo3; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 3. Visits the Clinical Experience site at least once per week to confer with the mentor and student; verify that student’s duties correlate with prior instruction; observe working conditions; help develop progressive skill-building activities; observe and evaluate student progress; and resolve questions, issues, or concerns. <span style="margin: 0in -19.8pt 0pt 0.75in; mso-list: l3 level1 lfo3; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 4. Counsels the student about his/her clinical experience, behavior, attitude, academics, etc. <span style="margin: 0in -0.1in 0pt 0.75in; mso-list: l3 level1 lfo3; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 5. Terminates the Clinical Experience when it serves the best interest of the student as determined in collaboration with the Clinical Mentor. <span style="margin: 0in -19.8pt 0pt 0.75in; mso-list: l3 level1 lfo3; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 6. Determines the student’s final grade for the Clinical Experience experience/activity. <span style="margin: 0in -19.8pt 0pt 0.75in; mso-list: l3 level1 lfo3; mso-text-indent-alt: -.25in; tab-stops: -1.0in .75in; text-indent: -0.75in;"> 7. Reinforces Clinical Experiences with related classroom instruction. ** Clinical Mentor (Healthcare Agency Representative)  ** <span style="margin: 0in 0in 0pt 0.75in; mso-list: l1 level1 lfo4; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 1. Recognizes that the student is enrolled in a Clinical Experience designed to prepare for a career in a Health Science or related occupation. <span style="margin: 0in 0in 0pt 0.75in; mso-list: l1 level1 lfo4; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 2. Provides supervision and instruction in each of the applicable tasks listed on the Training Plan to assist the student in acquiring those competencies necessary for success in the career objective. <span style="margin: 0in 0in 0pt 0.75in; mso-list: l1 level1 lfo4; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 3. Evaluates and documents student progress. <span style="margin: 0in 0in 0pt 0.75in; mso-list: l1 level1 lfo4; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 4. Employs a non-discrimination policy with regard to race, color, handicap, sex, religion, national origin, creed, or age. <span style="margin: 0in 0in 0pt 0.75in; mso-list: l1 level1 lfo4; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 5. Adheres to wage and hour; child labor; and all other federal, state, and local laws pertaining to student employment. <span style="margin: 0in 0in 0pt 0.75in; mso-list: l1 level1 lfo4; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 6. Provides training to the student for the time required for the Clinical Experience. <span style="margin: 0in 0in 0pt 0.75in; mso-list: l1 level1 lfo4; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 7. Completes and return the Clinical Experience Evaluation and returns it to Health Science Instructor on the required date.<span style="font-family: 'Tahoma','sans-serif'; font-size: 11pt;"> <span style="margin: 0in 0in 0pt 0.75in; mso-list: l1 level1 lfo4; mso-text-indent-alt: -.25in; tab-stops: -1.0in; text-align: justify; text-indent: -0.75in;"> 8. Agrees to adhere to the following: **// No person shall be denied employment, be excluded from participation in, be denied the benefits of, or be subjected to discrimination in any program or activity on the basis of disability, sex, race, religion, national origin, color, or age. Ref: Sec. 1983, Civil Rights Act, 42 U.S.C.; Title VI and VII, Civil Rights Act of 1964; Rehabilitation Act of 1973, Sec. 504; Age Discrimination in Employment Act; Equal Pay Act of 1963; Title IX of the Education Amendment of 1972. LEA contact Title IX Coordinator: P.O. Box __302101, Montgomery, Alabama 36130-2101__ or call __(334) 242-8444__. //**   <span style="font-family: 'Tahoma','sans-serif'; font-size: 11pt;"> <span style="font-family: 'Tahoma','sans-serif'; font-size: 11pt;"> <span style="font-family: 'Tahoma','sans-serif'; font-size: 11pt;"> <span style="font-family: 'Tahoma','sans-serif'; font-size: 11pt;"> (Healthcare Agency Representative)  ||     ||   Student   ||
 * Health Science **
 * Parent/Guardian  ||     ||   Clinical Mentor
 * Parent/Guardian  ||     ||   Clinical Mentor
 * Health Science Instructor  ||     ||   School Administrator   ||     ||   Date   ||
 * Health Science Instructor  ||     ||   School Administrator   ||     ||   Date   ||