HomeMy WebLinkAboutCity of Tamarac Resolution R-2019-080 TR#13304
August 28, 2019
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CITY OF TAMARAC, FLORIDA
RESOLUTION NO. 2019- �
A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF
TAMARAC, FLORIDA, APPROVING A FIVE (5) YEAR-TERM
AGREEMENT FOR EMERGENCY MEDICAL SERVICES (EMS)
INTERNSHIP PROGRAM BETWEEN THE CITY OF TAMARAC
AND BROWARD COLLEGE TO ALLOW EMS STUDENTS TO
RIDE ALONG ON CITY'S FIRE RESCUE VEHICLES AS PART OF
A PRECEPTORSHIP PROGRAM AND RECEIVE EDUCATION
AND TRAINING FROM TAMARAC FIRE RESCUE PERSONNEL
WITH AN EFFECTIVE DATE UPON EXECUTION BY ALL
PARTIES, AUTHORIZING APPROPRIATE CITY OFFICIALS TO
EXECUTE AN AGREEMENT FOR EMS INTERNSHIP
PROGRAM; PROVIDING FOR CONFLICTS; PROVIDING FOR
SEVERABILITY; AND PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the City of Tamarac through the Fire Department provides
Emergency Medical Services (EMS) and Advanced Life Support (ALS) transport; and
WHEREAS, Broward College requires an agreement for their EMS Internship
Programs to be executed with participating agencies for their EMS students to ride
along with each prospective agency; and
WHEREAS, Broward College has requested that the City of Tamarac allow
Emergency Medical Technician (EMT) and Paramedic students to ride along on the
City's fire rescue units as part of a Preceptorship Program in order to gain the required
experience needed to become a State of Florida Certified EMT and/or Paramedic under
Chapter 64J-1, Florida Administrative Code; and
WHEREAS, the Agreement for EMS Internship Program is attached here to as
Exhibit 1, and the City Acknowledgement of Responsibility to Maintain Confidentiality of
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August 28, 2019
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Medical Information, the Health and Background Screening Attestation, and the
Assumption of Risk and Release of Liability are attached here to as Exhibits A, B and C
respectively; and
WHEREAS, the Agreement for EMS Internship Program also enables the City to
have our own personnel if attending school to ride on our rescue vehicles; and
WHEREAS, the Fire Chief recommends the approval and execution of the
Agreement for EMS Internship Program with Broward College; and
WHEREAS, the City Commission of the City of Tamarac, Florida deems it to be
in the best interest of the citizens and residents of the City of Tamarac to approve the
Agreement for EMS Internship Program with Broward College to allow EMS students to
ride on Tamarac Fire Rescue vehicles.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE
CITY OF TAMARAC, FLORIDA:
SECTION 1: The foregoing "WHEREAS" clauses are hereby ratified and
confirmed as being true and correct and are hereby made a specific part of this
Resolution. All Exhibits attached hereto are expressly incorporated herein and made a
part hereof.
SECTION 2: That the Commission hereby approves the Agreement for EMS
Internship Program between the City of Tamarac and Broward College to allow EMS
students to ride on City Fire Rescue vehicles as part of a Preceptorship Program. The
appropriate City Officials are hereby authorized to execute the Broward College
Agreement for EMS Internship Program, (attached hereto as Exhibit 1).
SECTION 3: That all Resolutions or parts of Resolutions in conflict herewith are
hereby repealed to the extent of such conflict.
TR#13304
August 28, 2019
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SECTION 4: If any clause, section, other part or application of this Resolution is
held by any court of competent jurisdiction to be unconstitutional or invalid, in part or
application, it shall not affect the validity of the remaining portions or applications of this
Resolution.
SECTION 5: This Resolution shall become effective immediately upon its
passage and adoption.
PASSED, ADOPTED AND APPROVED this a day of , 2019.
th J4
MICHELLE J. GOMEZ,
MAYOR
ATTEST:
PATRICIA TEU EL, AMC
CITY CLERK
RECORD OF COMMISSION VOTE:
MAYOR GOMEZ
DIST 1: COMM. BOLTON
DIST 2: COMM. GELIN
DIST 3: COMM. FISHMAN
DIST 4: V/M PLACKO
I HEREBY CERTIFY THAT I HAVE
APPROVED THIS RESOLUTION
AS TO FORM
Ss MUEL S. GOREN
CITY ATTORNEY
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AGREEMENT
THIS AGREEMENT is made and entered into as of this day of ,'.fir~`
20 m , by and between
CITY OF TAMARAC
(hereinafter referred to as "City"),
A MUNICIPAL CORPORATION, of the State of Florida,
whose principal place of business is
7525 NW 88th Avenue, Tamarac, Florida 33321
and
THE DISTRICT BOARD OF TRUSTEES OF BROWARD COLLEGE, FLORIDA
(hereinafter referred to as "School"),
a political subdivision of the State of Florida, whose principal place of business is
111 East Las Olas Boulevard Fort Lauderdale, FL 33301
WHEREAS, School operates an EMS Training School, and is conducting educational
programs for the purpose of providing skilled workers who can provide emergency medical
services; and
WHEREAS, City has the facilities which are available to assist in the provision of the
said educational programs and desires to participate in the education programs for the benefit of
the entire community.
NOW, THEREFORE, in consideration of the premises and of the mutual covenants
contained herein and other good and valuable consideration, the receipt and sufficiency of which
is hereby acknowledged, the Parties hereby agree as follows:
1.0 Recitals. The parties agree that the foregoing recitals are true and correct and that such
recitals are incorporated herein by reference.
2.0 Purpose of Agreement.
2.01 Program Purpose. The education of the student shall be the primary purpose
of the program.
2.02 Term of agreement. The term of this Agreement shall be for a period of five (5)
years, commencing on August 1st, 2019 , and concluding on
August 1st, 2024 , unless terminated by either party. The parties may agree to
renew this Agreement for an additional one (1) year term upon the parties executing an
amendment to this Agreement.
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2.03 Instruction and Curriculum. School shall be responsible, at its sole expense,
for provision of classroom instruction, the selection of students, establishment of curriculum,
maintenance of records, evaluation of programs, and all educational experiences through the
employment of certified instructors through compliance with all applicable guidelines. All
faculty provided by School shall by duly licensed, certified or otherwise qualified to participate
in the program. Neither the School nor any participating student of faculty member shall
interfere with or adversely affect City's operations or City's provision of emergency medical
services. College shall be responsible for the implementation and operation of the clinical
component of its program at Facility ("Program"), All students, faculty, employees, agents and
representatives of School participating in the Program while on Facility shall be accountable to
Facility's Administrator. College shall be responsible for causing all students, faculty,
employees, agents and representatives of the School to comply with the terms of this Agreement
and all applicable City rules, policies, procedures, codes, and ordinances, which may include
required training, drug screenings, and a successful background check.
2.04 Telephone Consultation. School shall provide faculty or school administration
for consultation with City by telephone at any given time during which students are on City's
premises without supervision by an instructor.
2.05 Course Materials. Upon request, School shall provide City copies of current
course outlines, course objectives, curriculum, philosophy and a list of faculty and their
qualifications.
2.06 Educational Plan. School faculty will prepare an educational plan in
conjunction with City staff prior to the placement of students with City. The training to be
provided to students shall be specified in writing and shall be based upon the needs of the student
to satisfy the objectives of the program. The faculty shall be responsible for maintaining
cooperative relationships with City staff City shall provide opportunities for participating
students to observe various aspects of paramedic training.
2.07 Patient Confidentiality. School and its participating students and faculty shall
keep strictly confidential and hold in trust all confidential information of City and/or its patients
and shall not disclose or reveal any confidential information to any third party without City's
express prior written consent. The School shall advise participating students and faculty that the
City will require the participating students to execute a Confidentiality Statement substantially
complying with the form attached hereto as Exhibit "A" and provide a copy of each student's
signed form to the CITY before participating. School and its participating students and
faculty shall comply with any applicable state or federal laws or regulations concerning patient
confidentiality of protected health information, including, but not limited to the Health Insurance
Portability and Accountability Act of 1996 ("HIPAA"). School shall insure that all of the
students have received proper training with respect to the requirements of HIPAA, and insure
that its faculty and students comply with all of the requirements of HIPAA. Unauthorized
disclosure of confidential information, patient information of protected health information shall
be a material breach of this Agreement and shall constitute cause for the immediate termination
of this Agreement. School shall immediately notify City of any unauthorized disclosure of
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confidential information, patient information or protected health information that comes to its
knowledge. School will not enter into any contracts with their persons to whom confidential
information, patient information or protected health information would be provided without the
express written consent of City and the imposition upon such third persons of the same duty to
safeguard said information. School's records relating to the use and disclosure of said
information shall be available to inspection upon reasonable notice to City or any federal or state
authority entitled to access to such information. The provisions of this section shall survive the
expiration or termination of this agreement.
2.07.01 The School and its agents, students, faculty, representatives and
employees agree to keep strictly confidential and hold in trust all confidential information
of the CITY and its Department of Fire Rescue and its patients and not disclose or reveal
any confidential information to any third party without the express prior written consent
of the CITY. The School will train all students related to HIPAA and HITECH
compliance in additional to any and all applicable laws prior to enrollment in any clinical
course.
2.08 Dress Code and Meals. City shall require the students to dress in accordance
with dress and personal appearance standards approved by the City. Students shall pay for their
own meals.
2.09 Students are Not City Employees. School, its faculty and its students shall in
no event become or be deemed to be employees, servants, agents, or volunteers of City.
2.10 No Compensation. Each party shall perform the duties and responsibilities
specified in this Agreement without compensation. Participating students shall be treated by
City as trainees and shall have no expectation of receiving compensation or future employment
from either party.
2.11 Discontinued Student Placement. City reserves the right to refuse or
discontinue the placement of students if School does not meet the professional educational
requirements and standards of City. City reserves the right to discontinue the availability of its
facilities and services to any student who does not continuously meet professional or other
requirements, qualifications and standards of City as determined by City. City reserves the right
to immediately remove from the program any student who behaves unprofessionally or poses an
immediate threat or danger to patients or personnel or to the quality of medical services.
2.12 Infectious Diseases and Student Immunizations. School shall be responsible
for advising all program participants of the requirement for compliance with the final regulations
issued by the Occupational Safety and Health Administration governing employee exposure to
blood borne pathogens in the workplace under Section VI(b) of the Occupational Safety and
Health Act of 1970, which regulations became effective March 6, 1992, and as may be amended
or superseded from time to time School shall advise students of the risk of infectious diseases
and that City is not responsible for exposure to infectious diseases that occur beyond their
reasonable control. School shall verify that students have received immunizations for Measles,
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Mumps, Rubella (MMR) Diphtheria and Tetanus (DT) and have received annual screening for
Tuberculosis. School shall be responsible for providing information and advising the
participating students and faculty of the applicable regulations issued by OSHA and for the
provision to participating students and faculty of(1) information and training about the hazards
associated with blood and other potentially infectious materials; (2) information and training
about the protective measures to be taken to minimize the risk of occupational exposure to
bloodborne pathogens; (3) training in the appropriate actions to take in an emergency involving
exposure to blood and other potentially infectious materials; and (4) information as to the reasons
the employee should participate in hepatitis B vaccination and post-exposure evaluation and
follow-up. The School shall preform and certify that is has conducted the health the background
checks of its participating students pursuant to the City's Health and Background Screening
Attestation, attached hereto Exhibit B.
2.13 Personal Property. City shall not be responsible for the personal property
belonging to School, School faculty, or School's students participating in the program.
2.14 Participant's Medical Care. School and/or the students participating in the
program shall be responsible for arranging for the students medical care and/or treatment, if
necessary, including transportation in the event of illness or injury while participating in the
program provided at City's premises. At the time of providing such services, City shall accept
assignment of the affected individual's insurance policy plus any co-pay and/or deductibles.
City shall not be responsible for costs involved in the provision of such services, the follow-up
care, or hospitalization.
3.0 General Insurance Requirements.
3.01 School shall provide City proof of professional liability insurance coverage with
minimum limits of$1,000,000 per claim, $3,000,000 per occurrence. Students shall be required to
be covered by their own health or accident insurance.
3.02. Insurance shall be in force until the obligations required to be fulfilled under the
terms of the Agreement are satisfied. In the event a insurance certificate provided indicates that
the insurance shall terminate and lapse during the period of this Agreement, then in that event,
either party shall furnish to the other party, at least forty-five (45) days prior to the expiration of
the date of such insurance, a renewed certificate of insurance as proof that equal and like
coverage for the balance of the period of the Agreement and extension thereunder is in effect.
The parties shall not be obligated to continue to perform services pursuant to this Agreement
unless all required insurance remains in full force and effect.
4.0. Indemnification.
4.01 The School agrees to be fully responsible to the City, its Commission, officers,
agents, servants and employees, from and against any and all claims, demands, or causes of
action of whatsoever kind or nature, and the resulting losses, costs, expenses, reasonable
attorneys' fees, liabilities, damages, orders,judgements, or decrees, sustained by the City or any
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third party arising out of, or by reason of, or resulting from the School's negligent acts, errors, or
omissions, but not for any claims, demands, or causes of action caused by the negligence of the
City.
4.02 If a claim is litigated and names City as a party defendant, City shall be held
harmless as to all costs and expenses associated with the litigation related to that claim, including
but not limited to, costs, attorneys' fees, paralegal expenses, attorneys' fees on appeal, monies
paid in settlement or monies paid to satisfy any judgment obtained herein.
4.03 The School and City agree that all students shall be required to sign the City's
Assumption of Risk and Release of Liability form, attached hereto as Exhibit C, as a prerequisite
to their participation with the City, its employees, or entry upon its facilities and vehicles.
4.04 The City and the School are political subdivisions of the State of Florida, and as
such are protected by sovereign immunity. Nothing contained herein is intended to nor shall act
as a waiver of the either Parry's sovereign immunity protection except as otherwise stated in
Florida Statute 768.28.
5.0. Independent Contractor. This Agreement does not create an employer/employee
relationship between the Parties. It is the intent of the Parties that School is an independent
contractor under this Agreement and not the City's employee for any purposes, including but not
limited to, the application of the Fair Labor Standards Act minimum wage and overtime
payments, Federal Insurance Contribution Act, the Social Security Act, the Federal
Unemployment Tax Act, the provisions of the Internal Revenue Code, the State Worker's
Compensation Act, and the State Unemployment Insurance law. City shall retain sole and
absolute discretion in the judgment of the manner and means of carrying out City's activities and
responsibilities hereunder provided, further that administrative procedures applicable to services
rendered under this Agreement shall be those of City, which policies of City shall not conflict
with School, State, or United States policies, rules or regulations relating to the use of City's
funds provided for herein. City agrees that it is a separate and independent enterprise from the
School, that it had full opportunity to find other business, that it has made its own investment in
its business, and that it will utilize a high level of skill necessary to perform the work. This
Agreement shall not be construed as creating any joint employment relationship between City
and the School and the School will not be liable for any obligation incurred by City, including
but not limited to unpaid minimum wages and/or overtime premiums.
6.0. Assignments; Amendments.
6.01. This Agreement, or any interest herein, shall not be assigned, transferred or
otherwise encumbered, under any circumstances, by either party without the prior written
consent of the other party. For purposes of this Agreement, any change of ownership of School
shall constitute an assignment which requires City approval. However, this Agreement shall run
to the City and its successors and assigns.
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6.02. It is further agreed that no modification, amendment or alteration in the terms or
conditions contained herein shall be effective unless contained in a written document executed
with the same formality and of equal dignity herewith.
7.0. No Contingent Fees. School warrants that it has not employed or retained any
company or person, other than a bona fide employee working solely for School to solicit or
secure this Agreement, and that it has not paid or agreed to pay any person, company,
corporation, individual or firm, other than a bona fide employee working solely for School any
fee, commission, percentage, gift, or other consideration contingent upon or resulting from the
award or making of this Agreement. For the breach or violation of this provision, the City shall
have the right to terminate the Agreement without liability at its discretion, to deduct from the
contract price, or otherwise recover the full amount of such fee, commission, percentage, gift or
consideration.
8.0. Notice. Whenever any party desires to give notice unto any other party, it must be
given by written notice, sent by registered United States mail, with return receipt requested,
addressed to the party for whom it is intended and the remaining party, at the places last
specified, and that places for giving of notice shall remain such until they shall have been
changed by written notice in compliance with the provisions of this section. For the present,
School and the City designate the following as the respective places for giving of notice:
City: Michael Cernech, City Manager
City of Tamarac
7252 NW 88th Avenue
Tamarac, FL 33321
Copy To: Samuel S. Goren, City Attorney
Goren, Cherof, Doody& Ezrol, P.A.
3099 East Commercial Boulevard, Suite 200
Fort Lauderdale, Florida 33308
Telephone No. (954) 771-4500
Facsimile No. (954) 771-4923
School: Broward College
Office of General Counsel
111 E. Las Olas Blvd.
Fort Lauderdale, FL 33301
(954) 201-7410
9.0. Binding Authority. Each person signing this Agreement on behalf of either party
individually warrants that he or she has the full legal power to execute this Agreement on behalf
of the party for whom he or she is signing, and to bind and obligate such party with respect to all
provisions contained in this Agreement.
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10.0. Legal Representation. It is acknowledged that each party had the opportunity to be
represented by counsel in the preparation of and contribution to the terms and conditions of this
Agreement and, accordingly, the rule that a contract shall be interpreted strictly against the party
preparing same shall not apply herein due to the joint contributions of both Parties.
11.0. Headings. Headings herein are for convenience of reference only and shall not be
considered on any interpretation of this Agreement.
12.0. Severability. If any provision of this Agreement or application thereof to any person or
situation shall to any extent, be held invalid or unenforceable, the remainder of this Agreement,
and the application of such provisions to persons or situations other than those as to which it
shall have been held invalid or unenforceable shall not be affected thereby, and shall continue in
full force and effect, and be enforced to the fullest extent permitted by law.
13.0. Governing Law. This Agreement shall be governed by the laws of the State of
Florida with venue lying in Broward County, Florida.
14.0. Attorney's Fees. In the event that either party brings suit for enforcement of this
Agreement, each party shall bear its own attorney's fees and costs.
15.0. Extent of Agreement. This Agreement represents the entire and integrated
agreement between the City and School and supersedes all prior negotiations, representations or
agreements, either written or oral.
16.0. Termination. This Agreement may be terminated without cause by either party upon
thirty (30) days written notice to the other party. Students participating in the Program at the
time of termination shall be allowed to complete the clinical education experience; such
completion period shall not exceed six (6) months, unless otherwise agreed to in writing by the
City and the School. During the completion period, the students and the School shall comply
with the terms and conditions of this Agreement. No student shall be enrolled after the date upon
which notice of termination has been provided.
17.0. Equal Employment Opportunity. In the performance of this Agreement, School shall
not discriminate against any firm, employee or applicant for employment or any other firm or
individual in providing services because of sex, age, race, color, religion, ancestry or national
origin.
18.0 Public Records._ In order to comply with Florida's Public Records Act (the "Act" ),
Chapter 119, Florida Statutes, and pursuant specifically to section 119.0701, Florida Statutes, as
may be amended, the School shall:
18.1 Keep and maintain public records that ordinarily and necessarily would be required
by the CITY in order to perform the services under the Agreement.
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18.2 Provide the public with access to public records on the same terms and conditions
that the CITY would provide the records and at a cost that does not exceed the cost
provided in Chapter 119, Florida Statutes, or as otherwise provided by law.
18.3 Ensure that public records that are exempt or confidential and exempt from public
records disclosure requirements are not disclosed except as authorized by law.
18.4 Meet all requirements for retaining public records and transfer, at no cost, to the
CITY all public records in possession of School upon termination of the Agreement and
destroy any duplicate public records that are exempt or confidential and exempt from
public records disclosure requirements. All records stored electronically must be
provided to the CITY in a format that is compatible with the information technology
systems of the CITY.
18.5 If the SCHOOL does not comply with a public records request, the CITY may
terminate this Agreement.
18.6 IF THE SCHOOL HAS QUESTIONS REGARDING THE
APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE
SCHOOL'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO
THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC
RECORDS, PATRICIA TEUFEL, CITY CLERK FOR THE CITY OF
TAMARAC, AT, PAT.TEUFEL, 7252 NW 88th AVENUE AVE,
TAMARAC, FL 33321.
19.0. Waiver. Any failure by City to require strict compliance with any provision of this
contract shall not be construed as a waiver of such provision, and City may subsequently require
strict compliance at any time, notwithstanding any prior failure to do so.
20.0. Counterparts. This Agreement may be executed in multiple counterparts, each of
which shall be deemed an original, and all of which together shall constitute one and the same
instrument.
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IN WITNESS OF THE FOREGOING, the Parties have set their hands and seals the
day and year first written above.
CITY
ATTEST: CITY ARAC FLORIDA:
PATRICIA TEUFEL, TY CLERK
MICHAE ERNF,CH
APPROVED AS TO FORM: CITY MANAGER
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OFFICE OF THEICIVATTORNEY
O o SCHOOL
U �S•cP• rsD5 ®= BROWARD COLLEGE
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(CORPOI , '•SEAL)5� By: ,of
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Title: V I(i2 keliVO /6lAC
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STATE OF Fib
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COUNTY OF eituAa )
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ON THIS day of I.l.l , 201 before me, the undersigned notary
public, personally appeared IV°SSC, V CA ,w , personally
known to me, or who has produced as identification, and is the person wfio
subscribed to the foregoing instrument and who acknowledged that (s)he executed the same on
behalf of said Corporation and that (s)he was duly authorized to do so.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
NO ARY PURL
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My Commission Expires:
t�`'�''• IACEv DIGGS NOFMEYER
f-• T'° Notary Public-State of Florida
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Bonded through National Notary Assn.
{002638732 2704-0501640} 10
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EXHIBIT A
ACKNOWLEDGMENT OF RESPONSIBILITY
TO MAINTAIN CONFIDENTIALITY OF MEDICAL INFORMATION
By virtue of your internship program or other association with the City of Tamarac, you
may need to know and, therefore, may be informed of certain patient medical
information that is necessary to perform your assigned duties.
State law, and in some instances federal law, mandates that personal information and
protected health information ("medical information") be kept confidential unless the
patient gives specific written authorization or unless compelled by court order or
subpoena, when certain conditions are met for release of medical information.
By signing this form, you acknowledge that you must maintain as confidential all
medical information regarding any patient which you obtain in conjunction with your
internship duties and responsibilities, and you further acknowledge that you may not
disseminate this medical information to or discuss the medical condition of a patient with
any person except those persons directly necessary to the performance of your duties
and responsibilities.
Breach of this confidentiality may result in monetary liability, civil, and/or criminal
penalties imposed by law, and shall subject interns to discipline up to and including
dismissal for violation of City rules.
Print Name of Student:
First MI Last Suffix
Signature of Student:
Date:
Witness:
Printed Name of Witness:
Received by: on
(Name) (Date)
For internal use only:
Date Received:
Recipient:
Effective: 10/29/2010 HIPAA Form
Tamarac
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EXHIBIT B
HEALTH AND BACKGROUND SCREENING ATTESTATION
HEALTH OF PROGRAM PARTICIPANTS. School affirms the Program Participant(s) listed
below have completed the following health screenings or documented health status as follows:
1. Tuberculin skin test within the past 12 months or documentation as a previous positive reactor
or a chest x-ray taken within the past 12 months; and
2. Proof of Rubella and Rubeola immunity by positive antibody titers or 2 doses of MMR; and
3. Varicella immunity, by positive history of chickenpox or proof of Varicella immunization; and
4. Proof of Hepatitis B immunization or completion of a certification of declination of vaccine, if
patient contact is anticipated. 5. Proof of Diphtheria Tetanus Toxide Booster within the last ten
years
INSURANCE. School affirms the Program Participant(s) listed below have health insurance
which is current and up-to-date for the term in which they will be participating.
BACKGROUND CHECKS. The School has conducted a retrospective background check on all
students assigned to the program and members of staff/faculty responsible for supervision and/or
instruction prior to their participation in clinical activities. Unless the Facility is notified in
writing, all background checks are negative. The background check included the following:
1. Social Security number verification.
2. Criminal Search(7 years)
3. Violent Sexual Offender& Predator registry
4. HHS/OIG/GSA
5. Other:
ATTENDING STUDENTS:
1.
2.
3.
STAFF:
1.
2.
College acknowledges this information will be available to all of affiliates
as reasonably necessary.
The District Board of Trustees of Broward College, Florida
Name:
Signature:
Title:
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EXHIBIT C
CITY OF TAMARAC
Assumption of Risk and Release of Liability
For and in consideration of being permitted to ride as an observer with the Tamarac Fire Rescue
Department in an emergency or other medically-related vehicle of the educational benefits to be
received, and in full recognition, understanding and appreciation of the basic nature of
emergency work, and the possibility that situations will arise which result in my being exposed
to physical harm or injury through, but not limited to, vehicle accidents, blood borne pathogens,
disease or violent patients, I do hereby agree to assume all known and unknown risks in
connection therewith. Further, I do hereby indemnify, hold harmless, release and forever
discharge the City of Tamarac, its officials, officers, agents and employees from any liability or
responsibility from any cause whatsoever, including negligence, for death or injury to my person
or damage or loss to my property that I may sustain or suffer resulting from or in any manner
connected with my participation in this activity.
The terms of this Agreement shall be in full force and effect on the date hereof and on any other
occasion hereafter when I accompany City of Tamarac agents.
I have read and understand the conditions of this program as stated above, and hereby voluntarily
assume all risks of loss, damage, injury or illnesses to me or my property, including death, which
may be sustained while a passenger of the City vehicle or incidental to accompanying one or
more City of Tamarac Fire Rescue agents while on duty.
This Release and Agreement shall be binding upon me and my heirs, executors, administrators,
personal representatives and assigns, and shall inure to the benefit of the said City, agents, public
officials and any person herein designated, and their heirs, executors, administrators, personal
representatives, assigns and successors in office.
I acknowledge that I am at least 18 years of age and that my participation is as an observer only
in an authorized City of Tamarac motor vehicle unit.
I agree that if any portion of this document is held invalid or unenforceable by a court of
competent jurisdiction, then the remaining portion shall nevertheless continue in full force and
effect.
I HAVE READ THIS DOCUMENT CAREFULLY, FULLY UNDERSTAND ITS CONTENTS
AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF
LIABILITY TO THE FULLEST EXTENT PERMITTED BY LAW.
Print Participant Name:
Participant Signature:
Date Signed:
", .'',F 13
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STATE OF FLORIDA
COUNTY OF BROWARD
The foregoing instrument was acknowledged before me this day of
,20 , by , who is personally
known to me or had produced , as
identification.
My Commission Expires: Notary Public, State of Florida at Large
Print Notary Name
Signature of Approving Chief
Qe°` >^Of a1 < (00263873.2 2704-0501640) 14
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EXHIBIT A
ACKNOWLEDGMENT OF RESPONSIBILITY
TO MAINTAIN CONFIDENTIALITY OF MEDICAL INFORMATION
By virtue of your internship program or other association with the City of Tamarac, you
may need to know and, therefore, may be informed of certain patient medical
information that is necessary to perform your assigned duties.
State law, and in some instances federal law, mandates that personal information and
protected health information ("medical information") be kept confidential unless the
patient gives specific written authorization or unless compelled by court order or
subpoena, when certain conditions are met for release of medical information.
By signing this form, you acknowledge that you must maintain as confidential all
medical information regarding any patient which you obtain in conjunction with your
internship duties and responsibilities, and you further acknowledge that you may not
disseminate this medical information to or discuss the medical condition of a patient with
any person except those persons directly necessary to the performance of your duties
and responsibilities.
Breach of this confidentiality may result in monetary liability, civil, and/or criminal
penalties imposed by law, and shall subject interns to discipline up to and including
dismissal for violation of City rules.
Print Name of Student:
First MI Last Suffix
Signature of Student:
Date:
Witness:
Printed Name of Witness:
Received by: on
(Name) (Date)
For internal use only:
Date Received:
Recipient:
Effective: 10/29/2010 HIPAA Form
Tamarac
r {00>_63873.2 2704-0,01610: 1 I
4
EXHIBIT B
HEALTH AND BACKGROUND SCREENING ATTESTATION
HEALTH OF PROGRAM PARTICIPANTS. School affirms the Program Participant(s) listed
below have completed the following health screenings or documented health status as follows:
1. Tuberculin skin test within the past 12 months or documentation as a previous positive reactor
or a chest x-ray taken within the past 12 months; and
2. Proof of Rubella and Rubeola immunity by positive antibody titers or 2 doses of MMR; and
3. Varicella immunity,by positive history of chickenpox or proof of Varicella immunization; and
4. Proof of Hepatitis B immunization or completion of a certification of declination of vaccine, if
patient contact is anticipated. 5. Proof of Diphtheria Tetanus Toxide Booster within the last ten
years
INSURANCE. School affirms the Program Participant(s) listed below have health insurance
which is current and up-to-date for the term in which they will be participating.
BACKGROUND CHECKS. The School has conducted a retrospective background check on all
students assigned to the program and members of staff/faculty responsible for supervision and/or
instruction prior to their participation in clinical activities. Unless the Facility is notified in
writing, all background checks are negative. The background check included the following:
1. Social Security number verification.
2. Criminal Search(7 years)
3. Violent Sexual Offender& Predator registry
4. HHS/OIG/GSA
5. Other:
ATTENDING STUDENTS:
1.
2.
3.
STAFF:
1.
2.
College acknowledges this information will be available to all of affiliates
as reasonably necessary.
The District Board of Trustees of Broward College, Florida
Name:
Signature:
Title:
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(00263873.2 2704-0501640)
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EXHIBIT C
CITY OF TAMARAC
Assumption of Risk and Release of Liability
For and in consideration of being permitted to ride as an observer with the Tamarac Fire Rescue
Department in an emergency or other medically-related vehicle of the educational benefits to be
received, and in full recognition, understanding and appreciation of the basic nature of
emergency work, and the possibility that situations will arise which result in my being exposed
to physical harm or injury through, but not limited to, vehicle accidents, blood borne pathogens,
disease or violent patients, I do hereby agree to assume all known and unknown risks in
connection therewith. Further, I do hereby indemnify, hold harmless, release and forever
discharge the City of Tamarac, its officials, officers, agents and employees from any liability or
responsibility from any cause whatsoever, including negligence, for death or injury to my person
or damage or loss to my property that I may sustain or suffer resulting from or in any manner
connected with my participation in this activity.
The terms of this Agreement shall be in full force and effect on the date hereof and on any other
occasion hereafter when I accompany City of Tamarac agents.
I have read and understand the conditions of this program as stated above, and hereby voluntarily
assume all risks of loss, damage, injury or illnesses to me or my property, including death, which
may be sustained while a passenger of the City vehicle or incidental to accompanying one or
more City of Tamarac Fire Rescue agents while on duty.
This Release and Agreement shall be binding upon me and my heirs, executors, administrators,
personal representatives and assigns, and shall inure to the benefit of the said City, agents, public
officials and any person herein designated, and their heirs, executors, administrators, personal
representatives, assigns and successors in office.
I acknowledge that I am at least 18 years of age and that my participation is as an observer only
in an authorized City of Tamarac motor vehicle unit.
I agree that if any portion of this document is held invalid or unenforceable by a court of
competent jurisdiction, then the remaining portion shall nevertheless continue in full force and
effect.
I HAVE READ THIS DOCUMENT CAREFULLY, FULLY UNDERSTAND ITS CONTENTS
AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF
LIABILITY TO THE FULLEST EXTENT PERMITTED BY LAW.
Print Participant Name:
Participant Signature:
Date Signed:
(00263873.2 2704-0501640) 13
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STATE OF FLORIDA
COUNTY OF BROWARD
The foregoing instrument was acknowledged before me this day of
,20 , by , who is personally
known to me or had produced , as
identification.
My Commission Expires: Notary Public,State of Florida at Large
Print Notary Name
Signature of Approving Chief
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