BETTY WHITE HEALTH CENTER

Graduate Nursing Program Adult-Gerontology Primary Care DNP Program Clinical Practicum and Residency Preceptor

AN AGREEMENT BETWEEN KENTUCKY STATE UNIVERSITY SCHOOL OF NURSING AND

___

(Name of Agency)

City_____State _____

The purpose of this agreement is to provide a working relationship between Kentucky State University

___ ___in providing learning

School of Nursing and

(Agency)

who is enrolled in for

opportunities for

(Student) (Course No. and Name)

. This agreement between Kentucky State University School of Nursing and Health

(Semester)

Sciences and ____ will be effective from ____ through

(Agency)

(Beginning Date)

.

(Ending Date)

Both parties agree:

Professional liability insurance coverage will be maintained by each party to this agreement in amounts deemed adequate by both parties with costs of the coverage borne by Kentucky State University for the students and by the agency for themselves. As evidence of such coverages, each will furnish to the other a certificate of such insurance prior to the commencement of this agreement and annually thereafter. Failure of either party to obtain and maintain such coverage shall be grounds for immediate termination of this agreement.

Kentucky State University School of Nursing agrees:

1. That faculty from Kentucky State University School of Nursing will provide indirect supervision for nursing students engaged in a mutually agreeable practicum experience with a preceptor at the agency.
2. That faculty of the School of Nursing will initiate and/or participate in conferences as mutually agreed upon with a designee of the agency for the purpose of discussing objectives of the learning experiences and student performance in caring for patients.
3. That the nursing faculty and students will work in accordance with the agency procedures and policies in making plans for the practicum experience.
4. That during the term of this Agreement, the School of Nursing shall endeavor to maintain approval and accreditation standards accepted and required by the State Board of Nursing and national and regional accrediting bodies.
5. That to the best of the School of Nursing and Health Science's knowledge all nursing students have met health and immunization requirements as outlined in Kentucky State University School of Nursing Health Policy prior to clinical experiences.

Preceptor Initials: ___