Clinical affiliation agreement

This form has to be present with a copy of an ID-card at the address where the
clinical affiliation is done.
A copy of this form, without a copy of an ID-card, has to be present within five
working days after the start of the period of clinical affiliation at the education
institute.
Personal information of the clinical affiliation student
Family name:
First name:
Date of birth:
Place of birth:
Nationality:
Residence permit required? Yes/no. If yes, number:
Residence address during period
of clinical affiliation:
Telephone at residence address:
Cellular telephone:
Students e-mail:
Telephone number of
parents/guardians:
E-mail of parents/guardians:
Information of the organisation offering the place of clinical affiliation:
Organisations name:
Address of clinical affiliation:
Telephone:
Fax:
E-mail:
CA supervisors name:
Information: Saxion Hogescholen Enschede
Institutes name: Saxion Hogescholen
School of Health
Postal adres: P.O. Box 70.000
7500 KB Enschede
Address: M.H. Tromplaan 28
Enschede
Telephone: +31 (0)88 0193525
E-mail of CA secretary: j.s.basut@saxion.nl
E-mail CA coordinator: r.timmers@saxion.nl
c.j.m.rensen@saxion.nl
CA teachers name:
CA teachers telephone number:
CA teachers e-mail address:

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Article 1:
The undersigned:
1. Representative of the organisation offering the Clinical Affiliation, hereafter called
the CA organisation.
.

2. Saxion Hogescholen Enschede, in this represented by the CA cordinator of the

School of Health, the Academy of Physiotherapy, hereafter called the
School ..
3. Clinical Affiliation student

Declare that they have agreed on the following conditions:

Article 2: The objective of the period of clinical affiliation

The objective of this clinical affiliation is that the student acquires experience with
the practical application of the knowledge and skills that he/she has already
acquired and acquiring new knowledge and skills for developing and acquiring
professional competencies necessary for the profession of physiotherapy.
The organisation offering the clinical affiliation and the School ensure that the CA
student is assigned tasks and responsibilities in correspondence with the CA
students competence level and the education objectives for the clinical affiliation
concerned. Therefore, this agreement is not an employment contract.
It is the students responsibility to discuss and determine the education objectives
with the organisation offering the clinical affiliation as well as to realise these
objectives.

Article 3: Scope of the clinical affiliation:

1. The clinical affiliation agreement is entered into with regard to: (please tick what is
applicable)
Competence level 1
Competence level 2
Competence level 3
2. The agreement is entered into for the period of:
- ... - ... till - -
3. The period of clinical affiliation will take place from Monday up to and including
Friday, for hours per week, in accordance with the work hours applying at
the organisation offering the clinical affiliation.
4. The CA student will not be present at the organisation offering the clinical
affiliation on:
5. The number of estimated ECTS for this period of clinical affiliation amounts to:

6. In addition to the hours of clinical affiliation stated in article 3.3, the CA student
will be given the opportunity to acquire experience during so-called on-call
service hours in so far as possible in the organisation offering the clinical
affiliation.

Article 4: Supervision and Evaluation

1. The School will appoint a CA teacher for the supervision of the student from the
School of Health.
2. The organisation offering the clinical affiliation will appoint a practical supervisor
for the supervision of the CA student at the organisation offering the clinical
affiliation.
3. The organisation offering the clinical affiliation will be responsible for the
supervision of the CA student in correspondence with the agreements between
the organisation and the School recorded in the Instructions on Clinical
Affiliation.
4. In the context of the supervision stated in article 4.1, regular evaluation
meetings will take place. What is applicable here is that the evaluation meetings
take place at least twice per period of clinical affiliation for competence level 3.
For these evaluation meetings, the assessment form has to be filled out.
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5. The CA student describes the number of hours of clinical affiliation in the
assessment form. This is checked and signed for approval at the end of the
period by the practical supervisor.
6. The assessment is given to the School of Health within five work days after the
final day of clinical affiliation at the end of the period of clinical affiliation after
it is seen by and discussed with the CA student and signed.

Article 5: Clinical affiliation agreements

1. The organisation offering the clinical affiliation offers the CA student the
necessary facilities for performing the tasks and realising the education
objectives with that.
2. The CA student is obliged to observe secrecy as described in the BIG Act (the Act
on Professions in Individual Health Care
3. The CA student is obliged to observe secrecy with regard to the activities during
the clinical affiliation at the organisation offering the clinical affiliation if the
organisation requests this.
4. Written products will be submitted to the organisation for approval before they
are offered to the School of Health.
5. The copyrights regarding the results realised belong to the CA student, unless
explicitly determined otherwise. Both the CA student and the School of Health
may use the results for internal ends without consulting the organisation
offering the clinical affiliation.
6. The CA student complies with all regulations and conditions of the organisation
offering the clinical affiliation.
7. The organisation offering the clinical affiliation will comply with the regulations
and indications provided by the school in the courses interest in so far as
possible.
8. If the CA student is unable to fulfill the clinical affiliation, he/she informs the
organisation and the School of this as soon as possible.
9. The organisation offering the clinical affiliation does not owe payment or any
other kind of wages.

Article 6: Social protection/Insurance

1. The organisation offering the clinical affiliation will protect the CA student
against any form of intimidation or discrimination in the work place.
2. In conformity with Dutch law (art. 7:658 paragraph 4 Civil Code), the
organisation offering the clinical affiliation is liable to injury or damage that the
CA student may suffer during the period of clinical affiliation.
3. The CA student ensures that an insurance is entered into with regard to
accidents and liability in accordance with Dutch law, either by the CA student
him/herself or by the organisation offering the clinical affiliation.
A. The student is responsible for his/her own health insurance.
B. The student is responsible for his/her own liability insurance for private
persons (Dutch abbreviation: AVP).
C. If a student, doing his/her period of clinical affiliation in The Netherlands,
causes damage to third parties during his/her activities at the organisation
offering the clinical affiliation, the organisations company liability insurance
is the first to apply. After all, the CA student is regarded as subordinate to
the employer in the context of Dutch law, and therefore, the employer has to
take care of the damage. If the CA student causes damage to the organisation
offering the clinical affiliation, his/her own liability insurance has to be
addressed first, and subsequently the organisations company liability
insurance. In the third instance, the policy of the Saxion Foundation can be
addressedl which includes secondary liability coverage, among other things.
In accordance with this liability insurance, students (including periods of
clinical affiliation in The Netherlands) are insured against the risk of being
held liable, which third parties may hold against them with regard to damage
they caused in doing work for or performing activities for the Saxion
Foundation. Damage includes damage to affairs or injury to persons as well
as damage that emerges from this. This coverage applies as supplementary to
ones own liability insurance.

D. In addition to the general exclusions to the coverage, such as, among other
things: deliberacy, damage under supervision / damage with or by a motor
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 vehicle, it is determined that the liability to damage in connection with
(infected) blood are explicitly excluded from the coverage of this insurance.
If the student does his/her period of clinical affiliation abroad, the student
him/herself is responsible for entering into a legal liability insurance.

Article 7: Disputes
The CA student will approach the practical supervisor of the organisation offering
the clinical affiliation first in the case of a dispute.
If the dispute cannot be solved between the practical supervisor and CA student, the
matter will be submitted to the CA student of the School of Health to try to find a
solution that is acceptable to all parties.

Article 8: The end and ending of the clinical affiliation

1. The period of clinical affiliation ends:
A. After the period as meant in article 3.
B. If the CA student ends his studies at the School of Health.
C. If all parties agree on ending the clinical affiliation.
D. In case the CA student dies.
E. In case of bankruptcy, moratorium or dissolution of the organisation offering
the clinical affiliation.
2. The organisation offering the clinical affiliation can end this agreement, after
hearing the CA student and clinical affiliation supervisor:
A. If the CA teacher determines that the CA student does not comply with the
organisations regulations or fails to follow the practical supervisors
indications.
B. If the CA student fails to comply with the agreements regarding secrecy as
meant in article 5.
C. If the CA student behaves in such a way that the organisation offering the
clinical affiliation cannot reasonably be required to accept this. The practical
supervisor informs the CA teacher of any ending of the clinical affiliation.
3. The School of Health can end this agreement, after hearing the CA teacher, the
CA student and practical supervisor, if the School of Health determines that the
clinical affiliation does not meet the education objectivews and/or the tasks
recorded in this agreement and/or clinical affiliation instructions, or if the CA
student cannot reasonably be required to continue the clinical affiliation. The CA
teacher informs the practical supervisor of any termination of the clinical
affiliation.

Article 9: General stipulations

1. Deviating from the articles in this agreement is only possible by way of a further
written agreement between the School of Health, CA student and organisation
offering the clinical affiliation.
2. This agreement is subject to Dutch law.

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Signing:
The undersigned confirm the correctness of all stipulations in this agreement and
approve of all of the starting points and articles in it.

Education institute: Place: Date: Signature:

Saxion Hogescholen: Enschede

Academie Gezondheidszorg

CA student: Place: Date: Signature:

Organisation offering the Place: Date: Signature:

clinical affiliation