Fillable Printable VA Form 10-0094b

VA Form 10-0094b

VA FORM 10-0094b

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MEDICAL EDUCATION AFFILIATION AGREEMENT

BETWEEN DEPARTMENT OF VETERANS AFFAIRS (VA),

AND A SCHOOL OF OSTEOPATHIC MEDICINE

AND ITS AFFILIATED PARTICIPATING INSTITUTIONS

VA NETWORK

VA MEDICAL CARE FACILITY (including city and state)

SCHOOL OF OSTEOPATHIC MEDICINE (including city and state)

AFFILIATED PARTICIPATING INSTITUTION #1 (including ECCOPT ID number, city, and state)

AFFILIATED PARTICIPATING INSTITUTION #2 (including ECCOPT ID number, city, and state)

AFFILIATED PARTICIPATING INSTITUTION #3 (including ECCOPT ID number, city, and state)

AFFILIATED PARTICIPATING INSTITUTION #4 (including ECCOPT ID number, city, and state)

BACKGROUND

Use when trainees are enrolled in an academic program accredited by the American Osteopathic Association

Bureau of Professional Education or the Executive Committee of the Council on Postdoctoral Training (ECCOPT)

This agreement, when duly executed and approved by the Department of Veterans Affairs (VA), establishes an

affiliation between VA, its Veterans Integrated Service Networks, the listed VA facilities, and the school of

osteopathic medicine and its affiliated participating institutions for the academic purposes of enhanced patient

care, education, and research. The osteopathic medical school and its affiliated participating institutions that are

signatories to this document are collectively referred to as “partner institutions.” All parties to this agreement have

a shared responsibility for the academic enterprise. The partner institutions accept primary responsibility for the

integrated education programs conducted with VA while VA retains full responsibility for the care of VA patients

and administration of its operation. Additional responsibilities are delineated below.

The provision of education for future health care providers and the conduct of research are statutorily defined

as VA missions. By virtue of the close relationships between VA and the nation’s academic institutions, VA plays

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leadership role in reshaping the education of future health care professionals to help meet the complex scope of

the nation’s health care delivery system. It is the intent of VA to maintain its long-standing practice of effective

affiliations with educational institutions for the purposes of contributing to continued excellence in VA patient

care and conducting joint academic programs that address health manpower needs throughout VA and the nation.

An affiliation agreement promotes common standards for patient care, resident and student education,

research, and staff appointments. The parties to the affiliation agreement also seek to avoid duplication of

academic assets. The parties enter into this affiliation in a spirit of mutual benefit to be achieved through an

equitable contribution of resources. The affiliation agreement is crucial to the partnership because it forms the

philosophical and, in some cases, the legal basis for numerous specific agreements that may be executed between

components of the affiliate and VA.

In entering into any agreements, VA and the affiliate have a responsibility to comply with federal laws and

VA policies concerning conflicts of interest. The existence of an affiliation agreement does not guarantee that

VA and the affiliate will enter into additional agreements. However, some institutions may have other agreements

including contracts, memoranda of understanding, or other written agreements.

TERMS OF AGREEMENT

RESPONSIBILITIES

Ultimate responsibility for the control and operation of VA facilities and programs rests with VA. Ultimate

responsibility for academic education rests with the signatory institutions. Through this agreement, a partnership

is created to enable enhanced patient care, education, and research.

The partner institutions comply with Title VI of the Civil Rights Act of 1964, section 504 of the

Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Public Law 104-91, and the Age

Discrimination Act of 1975, and all related regulations, and assures that they do not, and will not, discriminate

against any person on the basis of race, color, sex, disability, or age under any program or activity receiving

federal financial assistance.

Nothing in this agreement is intended to be contrary to state or federal laws. In the event of conflict between

terms of this agreement and any applicable state or federal law, that state or federal law will supersede the terms

of this agreement. In the event of conflict between state and federal law, federal law will govern.

When providing professional services covered by this agreement, protection of faculty members (except those

providing services to VA under a contract) and trainees of the affiliated institution from personal liability while at

a VA health care facility will be that which is provided under the Federal Employees Liability Reform and Tort

Compensation Act 28 U.S.C.2679 (b)-(d).

1. The school of osteopathic medicine has the following responsibilities:

A. Operate and manage the school of osteopathic medicine and its associated residency programs and assume

overall responsibilities for the educational programs.

B. Maintain accreditation by the nationally recognized accreditation entities, the American Osteopathic

Association Bureau of Professional Education for osteopathic medical students and the Executive Committee of

the Council on Postdoctoral Training (ECCOPT) for osteopathic medical residents.

C. Encourage school of osteopathic medicine faculty to accept positions as VA medical staff and assure that

academic standards are met.

D. Enable school of osteopathic medicine faculty appointments and appointments to school of osteopathic

medicine committees and administrative positions for VA staff.

E. Recommend members for the VA Affiliation Partnership Council and its subcommittees. Members will

include the osteopathic medical school dean and senior faculty members from appropriate divisions of the

osteopathic medical school and affiliated participating institutions.

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3. VA has the following responsibilities:

A. Operate and manage the VA facility and maintain accreditation by the Joint Commission on Accreditation

of Healthcare Organizations (JCAHO) and other accrediting entities.

B. Appoint qualified health care professionals, as appropriate, as full-time or part-time staff of the facility,

who will provide supervision of trainees and provide veteran patient care.

C. Participate with the sponsoring institution in the academic programs of education and research, provide an

appropriate learning environment, and supply sufficient resources for appropriate conduct of such programs.

F. Orient trainees and faculty to the VA facility and inform them that they are subject to VA rules and

regulations while in a VA facility.

D. Assure that staff with appropriate credentials will supervise trainees.

E. Establish minimal qualifications for trainees coming to VA for academic programs.

G. Review and sign appropriate educational program letters of agreement prepared by the sponsoring

institution for trainees.

H. Ensure that all trainees who will be assigned to VA receive appropriate VA appointments.

I. Evaluate the trainee’s performance and conduct in mutual consultation with the program director and

according to the guidelines outlined in the approved curriculum and accepted standards.

J. Dismiss any trainee from VA assignment in accordance with VA Handbook 5021, Part VI, Paragraph 15 or

Paragraph 18, whichever paragraph applies.

K. Encourage faculty appointments at the sponsoring institution for VA staff.

M. Conduct periodic reviews of academic programs and policies according to VA policies.

L. Appoint VA and appropriate sponsoring institution program faculty to the VA Partnership Council and its

subcommittees. Program faculty will be chosen based on the extent of involvement in the VA training program

and geographic proximity to the VA facility.

2. The partner institutions have the following responsibilities:

A. Maintain accreditation by the Executive Committee of the Council on Postdoctoral Training (ECCOPT)

for osteopathic medical residents.

B. Authorize VA to receive from ECCOPT, and ECCOPT to provide VA, pursuant to a Memorandum of

Understanding between VA and ECCOPT, with letters of notification sent by ECCOPT to each institution having

graduate osteopathic medical education programs with which VA is affiliated.

C. Participate in the supervision of integrated academic programs at VA.

D. Select residents for academic programs involving VA, the school of osteopathic medicine, and the

affiliated participating institutions. Residents accepted for assignment at VA facilities must have the qualifications

and credentials as agreed upon by the school of osteopathic medicine, the affiliated participating institutions, and

VA.

E. Develop educational program letters of agreement for each VA health care facility that provides a resident

with educational experience that is one month or longer in duration. These agreements must identify faculty who

will teach, supervise, and evaluate resident performance; oversee duty hours; outline resident educational

objectives; specify periods of resident assignment; and establish policies and procedures for maintaining resident

education during the assignment.

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TERMINATION OF AFFILIATION AGREEMENT

This affiliation agreement is in force until further notice and supersedes any previous affiliation

agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care

and educational commitments, or by written notice by either party 6 months in advance of the next training

experience.

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SCHOOL OF OSTEOPATHIC MEDICINE AND AFFILIATED PARTICIPATING

INSTITUTIONS SIGNATURE PAGES

Requires signature of Designated Institutional Official (DIO) for each

affiliated participating institution listed on page one

Signature of DIO for the Affiliated Participating Institution #1 (Please

Signature of DIO for the Affiliated Participating Institution #2 (Please

Date of Signature Date of Signature

Typed Name of Individual Signing Above Typed Name of Individual Signing Above

Typed Title of Individual Signing Above Typed Title of Individual Signing Above

Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution

Signature of Designated Legal Signer for the Affiliated Participating

Institution #1 (Please sign in ink.)

Signature of Designated Legal Signer for the Affiliated Participating

Institution #2 (Please sign in ink.)

Date of Signature Date of Signature

Typed Name of Individual Signing Above Typed Name of Individual Signing Above

Typed Title of Individual Signing Above Typed Title of Individual Signing Above

Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution

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Signature of DIO for the Affiliated Participating Institution #3 (Please

Signature of DIO for the Affiliated Participating Institution #4 (Please

Date of Signature Date of Signature

Typed Name of Individual Signing Above Typed Name of Individual Signing Above

Typed Title of Individual Signing Above Typed Title of Individual Signing Above

Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution

Signature of Designated Legal Signer for the Affiliated Participating

Institution #3 (Please sign in ink.)

Signature of Designated Legal Signer for the Affiliated Participating

Institution #4 (Please sign in ink.)

Date of Signature Date of Signature

Typed Name of Individual Signing Above Typed Name of Individual Signing Above

Typed Title of Individual Signing Above Typed Title of Individual Signing Above

Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution

Signature of Dean or Equivalent Responsible Official for the School of

Osteopathic Medicine (Please sign in ink.)

Date of Signature

Typed Name of Individual Signing Above

Typed Title of Individual Signing Above

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DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE

Signature of VA Designated Education Official (Please sign in ink.)

Date of Signature

Typed Name of Individual Signing Above

Typed Title of Individual Signing Above

Signature of Director or Equivalent Responsible Official for the VA

Healthcare Facility (Please sign in ink.)

Signature of VISN Director or Designee for Department of Veterans

Affairs (Please sign in ink.)

Date of Signature Date of Signature

Typed Name of Individual Signing Above Typed Name of Individual Signing Above

Typed Title of Individual Signing Above Typed Title of Individual Signing Above

Signature of Chief Academic Affiliations Officer, VHA Office of

Academic Affiliations, VA Central Office (Please sign in ink.)

Date of Signature

Typed Name of Individual Signing Above

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