UD - Memo - Nursing Program
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MEMORANDUM
July 7,2005
TO:
The Honorable Mayor and City Council Members
FROM:
Michael C. Van Milligen, City Manager
SUBJECT: University of Dubuque/City of Dubuque Memorandum of Agreement
Public Health Specialist Mary Rose Corrigan recommends City Council approval of a
Memorandum of Agreement with the University of Dubuque for clinical site usage for
the University of Dubuque's nursing program.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
111 j Lft II IJ?le>.
Michael C. Van Milligen
MCVM/jh
Attachment
cc: Barry Lindahl, Corporation Counsel
Cindy Steinhauser, Assistant City Manager
Mary Rose Corrigan, RN, Public Health Specialist
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MEMORANDUM
FROM:
Michael C. Van Millig~nft~er
Mary Rose Corrigan, ~~, \Jublic Health Specialist
July 7, 2005
TO:
SUBJECT: University of Dubuque/City of Dubuque Memorandum of Agreement
INTRODUCTION
The memorandum provides information regarding an agreement between the University
of Dubuque (UD) and the City of Dubuque for UD's nursing program clinical site usage.
BACKGROUND
The University of Dubuque has recently established a BSN nursing program and is
establishing partnerships and clinical opportunities for their students to practice various
types of nursing care and nursing functions.
DISCUSSION
The attached agreement is a standard agreement given to all UD clinical sites for their
nurses to gain experience under the supervision of a clinical instructor. Examples of
clinical experiences nursing students will have with the City of Dubuque Health Services
Department include:
· shadowing and observing the various activities of the Health Services
Department;
· working on community-based education projects for lead, Healthy Homes
Initiative, or other targeted health education efforts;
· performing community-based surveys to collect health data, etc.
The City offers similar nursing clinical opportunities to the Clarke College nursing
program.
BUDGET IMPACT
No expenses or revenues are associated with the attached agreement.
RECOMMENDATION
It is recommended that the City Council authorize the City Manager and the Public
Health Specialist to sign the Memorandum of Agreement with University of Dubuque on
behalf of the City of Dubuque.
CITY COUNCIL ACTION
Authorize the City Manager and the Public Health Specialist to sign the Memorandum of
Agreement with the University of Dubuque for clinical site usage for UD's nursing
program.
MRC/cj
UNIVERSITY oj
DUBUQUE
2000 University Avenue · Dubuque, IA 52001-5099
FROM:
Kathryn J. Dolter, RN, PhD, LTC, US Army (Retired)
Chair, University of Dubuque Nursing Program
2000 University Avenue
Dubuque, IA 52001-5099
kdolter@dbq.edu
Phone: 563-589-3561
Fax: 563-589-3572
DATE:
June 7, 2005
TO:
Barry A. Lindahl, ESQ
Corporation Counsel, City of Dubuque
Suite 330
Harbor View Place
300 Main Street
Dubuque, IA 52001-6944
SUBJECT:
Memorandum of Agreement between the University of Dubuque (UD) and the
City of Dubuque Regarding Clinical Site Usage for UD's Nursing Program
(August, 2005-August, 2006)
1. Enclosed are two copies of the revised UD/City of Dubuque Memorandum of Agreement with
attachments (Insurance Schedule and Insurance Endorsements). Also included is the University
of Dubuque's Certificate ofInsurance.
2. Please let me know if you have any questions or concerns relative to the proposed UD/City of
Dubuque Memorandum of Agreement. My contact information is kdolter@dbq.edu or 563-589-
3561.
1/ () j(j\(ji
Y-~r--Y -U "11
Kathryn J. Dolter
Chair, Nursing Program
The University of Dubuque
Enclosures (2):
UD/City of Dubuque Memorandum of Agreement with Insurance Schedule C and Insurance
Endorsement (2 copies)
University of Dubuque Certificate of Insurance
School oj BUSiness · School oj Liberal Arts · School oj ProJessional Programs · Theological Seminary
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MEMORANDUM OF AGREEMENT BETWEEN
UNIVERSITY OF DUBUQUE NURSING PROGRAM
AND
THE CITY OF DUBUQUE
THIS AGREEMENT is entered into by and between UNIVERSITY OF DUBUQUE,
hereinafter referred to as "UNIVERSITY," and THE CITY OF DUBUQUE, hereinafter referred
to as "AFFILIATE," and shall govern the use of AFFILIATE'S facilities by the faculty and
nursing students of UNIVERSITY when assigned to AFFILIATE.
WHEREAS, the health care professions are committed to the improvement of the
delivery of health care in the United States;
WHEREAS, the nursing profession is an integral part of this delivery system and is
committed to the improvement of the quality of the educational process of those who choose to
practice in this profession;
WHEREAS, UNIVERSITY has exhibited a commitment to the development of quality
education in its nursing program;
WHEREAS, the continued maintenance of quality education rests in part upon the
excellence of the clinical experiences provided the student;
WHEREAS, UNIVERSITY recognizes AFFILIATE'S primary responsibility is for the
provision of quality health care;
WHEREAS, UNIVERSITY recognizes that the rights of clients/the community have
priority over the education of health professionals;
WHEREAS, AFFILIATE has demonstrated a commitment to excellence in health care
and the provision of clinical resources for learning by students of nursing; and
WHEREAS, both UNIVERSITY and AFFILIATE recognize that through cooperative
efforts the advancement of these commitments will be enhanced.
NOW, THEREFORE, in consideration of the mutual covenants of each party, IT IS
AGREED as follows:
ARTICLE I
UNIVERSITY RESPONSIBILITIES
I. The standard of philosophy of education and nursing; the instructional plan including
content, objectives and clinical experiences desired; and the preparation of all
instructional schedules including the number of hours of clinical practice shall be the
responsibility of UNIVERSITY.
2. UNIVERSITY shall verify that each student and faculty member assigned to care for
clients has on record a physical examination showing general good health.
UNIVERSITY shall verify that each student assigned to care for clients has been
informed of and will abide by employee infection policies. Students must have proof of
two (2) MMR vaccinations (mumps, measles and Rubella) or documented immunity
against measles, mumps, and rubella; documentation of Hepatitis B immunization or
immunity to Hepatitis B or a signed statement declining such vaccination; and a negative
two-step PPD test or chest x-ray within the last year, or persons with a previous positive
PPD result must have a history of a subsequent negative chest x-ray and a current
completion of the tuberculosis questionnaire.
3. To the fullest extent permitted by law, UNIVERSITY shall indemnify and hold harmless
AFFILIATE from and against all claims, damages, losses and expenses, including but not
limited to attorneys' fees, arising out of or resulting from performance of the Agreement,
provided that such claim, damages, loss or expense is attributable to bodily injury,
sickness, disease or death, or injury to or destruction of property including loss of use
resulting therefrom, but only to the extent caused in whole or in part by the negligent acts
or omissions of UNIVERSITY, or anyone whose acts UNIVERSITY may be liable,
regardless of whether or not such claim, damage, loss or expense is caused in part by a
party indemnified hereunder.
4. UNIVERSITY will maintain during the term of this Agreement insurance as set forth in
the attached Insurance Schedule.
5. UNIVERSITY shall ensure all nursing faculty are currently licensed to practice nursing
in the State of Iowa. Individuals are also considered "currently licensed" when licensed
in another state and recognized for licensure in Iowa, pursuant to the nurse licensure
compact contained in Section 152E.I, Code of Iowa.
6. The clinical instructor (faculty member) will be selected by UNIVERSITY and is
responsible for the learning experience of the student and their general provision. The
faculty will provide a mechanism for communication between the AFFILIATE staff and
the faculty when the AFFILIATE staff provides direct supervision for specific learning
experiences. The UNIVERSITY shall withdraw from the clinical area any student whose
work, conduct or health may have a detrimental effect on clients or personnel.
7. UNIVERSITY faculty and students shall maintain the confidentiality of all AFFILIATE
records and clients that they encounter. Students and faculty shall sign Workforce
Confidentiality Agreements prior to participating in their clinical experience and shall be
subject to the AFFILIATE's policies respecting the confidentiality of medical
information.
8. UNIVERSITY shall provide Health Insurance Portability and Accountability (HIP AA),
Family Educational Rights and Privacy Act (FERP A), and 42 CFR Part 2 training to all
students and faculty members before they are assigned to AFFILIATE.
10. UNIVERSITY shall provide proof of criminal background and child/adult abuse or
neglect registry checks on all students and faculty before they are assigned to
AFFILIATE.
11. UNIVERSITY, its students, faculty and employees hereby agree they shall be bound by
and comply with all federal, state and local laws, ordinances or regulations, Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO) or other
applicable accrediting body standards and accepted standards of practice applicable to
student training.
12. UNIVERSITY shall provide instruction and training on child abuse, dependent adult
abuse and mandatory reporting laws for health care professionals.
13. UNIVERSITY shall obtain and maintain preceptor agreements with individual preceptors
for internship experiences. Preceptor agreements shall be approved by the preceptor's
clinical director or supervisor. The UNIVERSITY shall provide AFFILIATE preceptors
with student evaluation forms to evaluate students where applicable.
14. UNIVERSITY shall ensure that all students are certified in cardiopulmonary resuscitation
(CPR) prior to any clinical experience. Additionally UNIVERSITY shall ensure that
students are certified in automatic external defibrillator (AED) and first aid prior to
community-based clinical AFFILIATE experiences.
15. UNIVERSITY faculty shall attend medication administration (PYXIS or other)
orientation prior to supervising students at the AFFILIATE when medication
administration is part of the student experience.
16. UNIVERSITY faculty shall be required to report errors and near misses to the
nurse/employee assigned to the client involved. The AFFILIATE nurse/employee shall
complete the error or near miss report with input from the student/faculty. The
UNIVERSITY has the responsibility to track individual student errors. However, the
AFFILIATE reserves the right to dismiss a student from the clinical area whose work
may have a detrimental effect on client care.
-3-
,
17. UNIVERSITY faculty and students shall utilize Intranet (when available) or print policies
and procedures at the point-of-care and shall utilize the information for client care and
client care documentation, as appropriate and in accordance with institutional policies
and procedures.
ARTICLE II
AFFILIATE RESPONSIBILITIES
1. AFFILIATE shall provide the equipment and supplies needed by students for providing
professional nursing care to clients.
2. AFFILIATE shall provide space when available for students and faculty when they are
on AFFILIA TE' s permises to facilitate recording and conferences.
3 . AFFILIATE shall accept the students and faculty of UNIVERSITY without
discrimination on the basis of sex, race, color, creed, marital status, age, national origin or
qualified handicap.
4. The responsibility for nursing care and related duties is retained by AFFILIATE when
nursing students and nursing personnel from outside sources are providing care within a
client care unit.
5. AFFILIATE shall maintain normal staffing and shall not rely on students to meet nursing
care requirements.
6. AFFILIA TE shall provide UNIVERSITY with a current copy of its policies and other
relevant documents which shall assist UNIVERSITY to develop appropriate learning
experiences for students.
7. AFFILIATE shall make available to UNIVERSITY the health and other pertinent records
and information regarding clients selected for the student assignment.
8. AFFILIATE may request UNIVERSITY to withdraw from the clinical area any student
whose work, conduct or health may have a detrimental effect on the clients or
AFFILIAA TE personnel. AFFILIA TE reserves the right not to accept any student who
has been previously discharged by AFFILIATE which would make acceptance as a
clinical practice student inexpedient. AFFILIATE shall notify the Chair, of the Nursing
Department at the UNIVERSITY regarding withdrawal or non-acceptance of a student.
The UNIVERSITY Nursing Department Chair shall respond to the request within two
working days.
9. AFFILIATE shall indemnify and save harmless UNIVERSITY, its employees and agents
from loss, damage expenses, attorney fees, and costs on account of the death, personal
-4-
injury and property damage to any person(s) caused by the negligence of AFFILIATE, its
officers, agents, or employees.
10. AFFILIATE shall allow faculty to attend an orientation program at the organization and
to the assigned client care area, as appropriate considering past experience and assessed
learning or proof of needs. AFFILIATE may request of faculty additional information
and competency as appropriate.
11. AFFILIATE preceptors shall provide UNIVERSITY with periodic written evaluations on
preceptorship students as applicable.
12. AFFILIATE shall advise clinical instructor (faculty member) immediately when a
situation arises with a student which AFFILIATE believes warrants immediate attention
by UNIVERSITY.
13. AFFILIATE shall allow students to be involved in quality improvement efforts and
projects, as appropriate to the students' experience. However, the students must share
results of their quality improvement efforts with the AFFILIATE.
14. AFFILIATE shall provide care, treatment, and or examination of students in case of
illness or accident occurring while on AFFILIATE's premises if it is available. This care,
treatment, and/or examination shall be provided at the student's own expense or billed to
the student's medical or hospitalization plan.
ARTICLE III
JOINT RESPONSIBILITIES
1. AFFILIATE and UNIVERSITY shall maintain communication to assure planning of
educational experiences and exchange of information regarding policies, problems and
new developments. In matters of major policy and/or significant concerns, the official
channel of communication shall be between the Chair of the Nursing Department of the
UNIVERSITY and the Public Health Specialist of the AFFILIATE.
2. The nursing faculty of UNIVERSITY and the personnel of AFFILIATE shall cooperate
in the assignment of students to learning experiences with daily objectives communicated
to AFFILIATE staff involved on any particular day, time, and place.
3. UNIVERSITY faculty and AFFILIATE personnel involved with the student learning
experience shall meet at the close of each semester to evaluate the clinical experience and
a report of this evaluation shall be forwarded to the Chair of the Nursing Department of
the UNIVERSITY and the Public Health Specialist at AFFILIATE.
-5-
4. The maximum number of students assigned to AFFILIATE during anyone instructional
period shall be established by mutual agreement and determined by the adequacy, extent
and variety of nursing experiences available for student learning.
5. Either party may terminate this Agreement upon 30 days written notice to the other party.
6. This Agreement shall be governed by the laws ofthe State oflowa.
7. This AGREEMENT shall be in effect from August I, 2005, through July 31, 2006.
IN WITNESS HEREOF, the parties have caused this AGREEMENT to be executed by
their respective authorized officers as of the day, month and year stated below.
AFFILIATE: CITY OF DUBUQUE
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Signed
City Manager
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Date
Signed
Public Health Specialist
Date
UNIVERSITY: UNIVERSITY OF DUBUQUE
Date ~ IJ 7/ J-005'
Signed ~a .W~
Vice-President ofF! ce
Signed ~r;;il
Chair, Nl sing Department
Date (p I:>. 7/ :zooS-
-6-
~I ,
MEMORANDUM OF AGREEMENT BETWEEN
UNIVERSITY OF DUBUQUE NURSING PROGRAM
AND
THE CITY OF DUBUQUE
THIS AGREEMENT is entered into by and between UNIVERSITY OF DUBUQUE,
hereinafter referred to as "UNIVERSITY," and THE CITY OF DUBUQUE, hereinafter referred
to as "AFFILIATE," and shall govern the use of AFFILIATE'S facilities by the faculty and
nursing students of UNIVERSITY when assigned to AFFILIATE.
WHEREAS, the health care professions are committed to the improvement of the
delivery of health care in the United States;
WHEREAS, the nursing profession is an integral part of this delivery system and is
committed to the improvement of the quality of the educational process of those who choose to
practice in this profession;
WHEREAS, UNIVERSITY has exhibited a commitment to the development of quality
education in its nursing program;
WHEREAS, the continued maintenance of quality education rests in part upon the
excellence of the clinical experiences provided the student;
WHEREAS, UNIVERSITY recognizes AFFILIATE'S primary responsibility is for the
provision of quality health care;
WHEREAS, UNIVERSITY recognizes that the rights of clients/the community have
priority over the education of health professionals;
WHEREAS, AFFILIATE has demonstrated a commitment to excellence in health care
and the provision of clinical resources for learning by students of nursing; and
WHEREAS, both UNIVERSITY and AFFILIATE recognize that through cooperative
efforts the advancement of these commitments will be enhanced,
NOW, THEREFORE, in consideration of the mutual covenants of each party, IT IS
AGREED as follows:
ARTICLE I
UNIVERSITY RESPONSIBILITIES
1. The standard of philosophy of education and nursing; the instructional plan including
content, objectives and clinical experiences desired; and the preparation of all
instructional schedules including the number of hours of clinical practice shall be the
responsibility of UNIVERSITY.
2. UNIVERSITY shall verify that each student and faculty member assigned to care for
clients has on record a physical examination showing general good health.
UNIVERSITY shall verify that each student assigned to care for clients has been
informed of and will abide by employee infection policies. Students must have proof of
two (2) MMR vaccinations (mumps, measles and Rubella) or documented immunity
against measles, mumps, and rubella; documentation of Hepatitis B immunization or
immunity to Hepatitis B or a signed statement declining such vaccination; and a negative
two-step PPD test or chest x-ray within the last year, or persons with a previous positive
PPD result must have a history of a subsequent negative chest x-ray and a current
completion of the tuberculosis questionnaire.
3. To the fullest extent permitted by law, UNIVERSITY shall indemnify and hold harmless
AFFILIATE from and against all claims, damages, losses and expenses, including but not
limited to attorneys' fees, arising out of or resulting from performance of the Agreement,
provided that such claim, damages, loss or expense is attributable to bodily injury,
sickness, disease or death, or injury to or destruction of property including loss of use
resulting therefrom, but only to the extent caused in whole or in part by the negligent acts
or omissions of UNIVERSITY, or anyone whose acts UNIVERSITY may be liable,
regardless of whether or not such claim, damage, loss or expense is caused in part by a
party indemnified hereunder.
4. UNIVERSITY will maintain during the term of this Agreement insurance as set forth in
the attached Insurance Schedule.
5. UNIVERSITY shall ensure all nursing faculty are currently licensed to practice nursing
in the State of Iowa. Individuals are also considered "currently licensed" when licensed
in another state and recognized for licensure in Iowa, pursuant to the nurse licensure
compact contained in Section 152E.l, Code of Iowa.
6. The clinical instructor (faculty member) will be selected by UNIVERSITY and is
responsible for the learning experience of the student and their general provision. The
faculty will provide a mechanism for communication between the AFFILIATE staff and
the faculty when the AFFILIATE staff provides direct supervision for specific learning
experiences. The UNIVERSITY shall withdraw from the clinical area any student whose
work, conduct or health may have a detrimental effect on clients or personnel.
7.
8.
10.
UNIVERSITY faculty and students shall maintain the confidentiality of all AFFILIATE
records and clients that they encounter. Students and faculty shall sign Workforce
Confidentiality Agreements prior to participating in their clinical experience and shall be
subject to the AFFILIATE's policies respecting the confidentiality of medical
information.
UNIVERSITY shall provide Health Insurance Portability and Accountability (HIP AA),
Family Educational Rights and Privacy Act (FERPA), and 42 CFR Part 2 training to all
students and faculty members before they are assigned to AFFILIATE.
UNIVERSITY shall provide proof of criminal background and child/adult abuse or
neglect registry checks on all students and faculty before they are assigned to
AFFILIATE.
11.
UNIVERSITY, its students, faculty and employees hereby agree they shall be bound by
and comply with all federal, state and local laws, ordinances or regulations, Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO) or other
applicable accrediting body standards and accepted standards of practice applicable to
student training.
12.
UNIVERSITY shall provide instruction and training on child abuse, dependent adult
abuse and mandatory reporting laws for health care professionals.
13.
UNIVERSITY shall obtain and maintain preceptor agreements with individual preceptors
for internship experiences. Preceptor agreements shall be approved by the preceptor's
clinical director or supervisor. The UNIVERSITY shall provide AFFILIATE preceptors
with student evaluation forms to evaluate students where applicable.
14.
UNIVERSITY shall ensure that all students are certified in cardiopulmonary resuscitation
(CPR) prior to any clinical experience. Additionally UNIVERSITY shall ensure that
students are certified in automatic external defibrillator (AED) and first aid prior to
community-based clinical AFFILIATE experiences.
15.
UNIVERSITY faculty shall attend medication administration (PYXIS or other)
orientation prior to supervising students at the AFFILIATE when medication
administration is part of the student experience.
16.
UNIVERSITY faculty shall be required to report errors and near misses to the
nurse/employee assigned to the client involved. The AFFILIATE nurse/employee shall
complete the error or near miss report with input from the student/faculty. The
UNIVERSITY has the responsibility to track individual student errors. However, the
AFFILIA TE reserves the right to dismiss a student from the clinical area whose work
may have a detrimental effect on client care.
-3-
17. UNIVERSITY faculty and students shall utilize Intranet (when available) or print policies
and procedures at the point-of-care and shall utilize the information for client care and
client care documentation, as appropriate and in accordance with institutional policies
and procedures.
ARTICLE II
AFFILIATE RESPONSIBILITIES
1. AFFILIATE shall provide the equipment and supplies needed by students for providing
professional nursing care to clients.
2. AFFILIATE shall provide space when available for students and faculty when they are
on AFFILIA TE' s permises to facilitate recording and conferences.
3 . AFFILIATE shall accept the students and faculty of UNIVERSITY without
discrimination on the basis of sex, race, color, creed, marital status, age, national origin or
qualified handicap.
4. The responsibility for nursing care and related duties is retained by AFFILIATE when
nursing students and nursing personnel from outside sources are providing care within a
client care unit.
5. AFFILIATE shall maintain normal staffing and shall not rely on students to meet nursing
care requirements.
6. AFFILIATE shall provide UNIVERSITY with a current copy of its policies and other
relevant documents which shall assist UNIVERSITY to develop appropriate learning
experiences for students.
7. AFFILIATE shall make available to UNIVERSITY the health and other pertinent records
and information regarding clients selected for the student assignment.
8. AFFILIATE may request UNIVERSITY to withdraw from the clinical area any student
whose work, conduct or health may have a detrimental effect on the clients or
AFFILIAA TE personnel. AFFILIATE reserves the right not to accept any student who
has been previously discharged by AFFILIATE which would make acceptance as a
clinical practice student inexpedient. AFFILIATE shall notify the Chair, of the Nursing
Department at the UNIVERSITY regarding withdrawal or non-acceptance of a student.
The UNIVERSITY Nursing Department Chair shall respond to the request within two
working days.
9. AFFILIATE shall indemnify and save harmless UNIVERSITY, its employees and agents
from loss, damage expenses, attorney fees, and costs on account of the death, personal
-4-
injury and property damage to any person(s) caused by the negligence of AFFILIATE, its
officers, agents, or employees.
10. AFFILIA TE shall allow faculty to attend an orientation program at the organization and
to the assigned client care area, as appropriate considering past experience and assessed
learning or proof of needs. AFFILIATE may request of faculty additional information
and competency as appropriate.
11. AFFILIATE preceptors shall provide UNIVERSITY with periodic written evaluations on
preceptorship students as applicable.
12. AFFILIATE shall advise clinical instructor (faculty member) immediately when a
situation arises with a student which AFFILIATE believes warrants immediate attention
by UNIVERSITY.
13. AFFILIATE shall allow students to be involved in quality improvement efforts and
projects, as appropriate to the students' experience. However, the students must share
results of their quality improvement efforts with the AFFILIATE.
14. AFFILIATE shall provide care, treatment, and or examination of students in case of
illness or accident occurring while on AFFILIATE's premises if it is available. This care,
treatment, and/or examination shall be provided at the student's own expense or billed to
the student's medical or hospitalization plan.
ARTICLE III
JOINT RESPONSIBILITIES
1. AFFILIATE and UNIVERSITY shall maintain communication to assure planning of
educational experiences and exchange of information regarding policies, problems and
new developments. In matters of major policy and/or significant concerns, the official
channel of communication shall be between the Chair of the Nursing Department of the
UNIVERSITY and the Public Health Specialist of the AFFILIATE.
2. The nursing faculty of UNIVERSITY and the personnel of AFFILIATE shall cooperate
in the assignment of students to learning experiences with daily objectives communicated
to AFFILIATE staff involved on any particular day, time, and place.
3. UNIVERSITY faculty and AFFILIATE personnel involved with the student learning
experience shall meet at the close of each semester to evaluate the clinical experience and
a report of this evaluation shall be forwarded to the Chair of the Nursing Department of
the UNIVERSITY and the Public Health Specialist at AFFILIATE.
-5-
4. The maximum number of students assigned to AFFILIATE during anyone instructional
period shall be established by mutual agreement and determined by the adequacy, extent
and variety of nursing experiences available for student learning.
5. Either party may terminate this Agreement upon 30 days written notice to the other party.
6. This Agreement shall be governed by the laws of the State of Iowa.
7. This AGREEMENT shall be in effect from August 1, 2005, through July 31,2006.
IN WITNESS HEREOF, the parties have caused this AGREEMENT to be executed by
their respective authorized officers as ofthe day, month and year stated below.
AFFILIATE: CITY OF DUBUQUE
Date
Signed
City Manager
Date
Signed
Public Health Specialist
UNIVERSITY: UNIVERSITY OF DUBUQUE
Date (p I~ 7/.J.. 0 05
Signed ~Q.W~
VIce-PresI ent of Fmance
Signed t.v~ rr:Jl1
Chair, NurS(ng Department
Date ~ / J.. 71 J.-OD5"
-6-
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INSURANCE SCHEDULE C
INSURANCE REQUIREMENTS FOR PROFESSIONAL SERVICES
1. All policies of insurance required hereunder shall be with an insurer
authorized to do business in Iowa. All insurers shall have a rating of A
better in the current A.M. Best Rating Guide.
2. All policies of insurance shall be endorsed to provide a thirty (30) day
advance notice of cancellation to the City of Dubuque,except for 10 day
notice for non-payment, if cancellation is prior to the expiration date. This
endorsement supersedes the standard cancellation statement on the
Certificate of Insurance.
3. UNIVERSITY shall furnish a signed Certificate of Insurance to the City of
Dubuque, Iowa for the coverage required in Paragraph 6 below. Such
Certificates shall include copies of the following endorsements:
a) Commercial General Liability policy is primary and non-
contributing.
b) Commercial General Liability additional insured
endorsement.
c) Governmental Immunities Endorsement.
UNIVERSITY shall also be required to provide Certificates of Insurance of
all subcontractors and all sub-sub contractors who perform work or services
pursuant to the provisions of this contract. Said certificates shall meet the same
insurance requirements as required of UNIVERSITY.
4. Each certificate shall be submitted to the contracting department of the City of
Dubuque.
5. Failure to provide minimum coverage shall not be deemed a waiver of
these requirements by the City of Dubuque. Failure to obtain or maintain
the required insurance shall be considered a material breach of this
agreement.
6. UNIVERSITY shall be required to carry the following minimum
coverage/limits or greater if required by law or other legal agreement:
a) COMMERCIAL GENERAL L1ABIL TIY
General Aggregate Limit
Products-Completed Operations
Aggregate Limit
$2,000,000
$1,000,000
April 2005
Personal and Advertising Injury Limit
Each Occurrence Limit
Fire Damage limit (anyone occurrence)
Medical Payments
$1,000,000
$1,000,000
$ 50,000
$ 5,000
b) Automobile $1,000,000 combined single limit.
Governmental Immunity endorsement identical or equivalent to form attached.
The City of Dubuque shall be named as an additional insured on General Liability
including "ongoing operations" coverage equivalent to ISO CG 20 10 0704.
c) WORKERS COMPENSATION & EMPLOYERS LIABILITY
Statutory for Coverage A
Employers Liability:
$ 100,000 each accident
$ 100,000 each employee-disease
$ 500,000 policy limit-disease
d) PROFESSIONAL LIABILITY $1,000,000
e) UMBRELLA/EXCESS LIABILITY $10,000,000
April 2005
ACORD. CERTIFICA TE OF LIABILITY INSURANCE OP 10 1~ DATE (MMlDDIYYYY)
UNIDUBl 06/06/05
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
cottingham & Butler, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
300 SECURITY BUILDING PO BX 28 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
DUBUQUE LA 52001
Phone: 563-587-5000 Fax:563-583-7339 INSURERS AFFORDING COVERAGE NAlC #
INSURED INSlRER A st. 'aul Fix. & H"Ein. Ins Co 24767
INSURER B Chicago Insurance Company 22810
university of Dubuque INSLl<ER c:
2000 Universit~ Avenue INSURER D'
Dubuque IA 520 1
INSURER E
COVERAGES
THE POliCIES OF INSURl'NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POliCY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCl.fIENTWITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS Of SUCH
POliCIES. AGGREGATE LIMITS SHO'Ml MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR[ TYPE OF INSURANCE POLICY NUMBER DATE (MMlDDIYY) DATE (MlNDDIYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
- 06/01/05 06/01/06 ~IV~IO"'IOV
A ~ COMMERCIAL GENERAL LIABILITY 6308572B663 PREMISES (Ea occurence) $ 100000
::::J CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $ 5000
-
PERSONAL & I'DV INJURY $ 1000000
-
GENERAL AGGREGATE $2000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2000000
I POLICY n j~& n LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $ 1000000
A ~ ANY AUTO 8108572B663 06/01/05 06/01/06 (Ea accident)
ALL OWNED AUTOS BODIL Y INJJRY
- $
SCHEDUlED AUTOS (Per person)
-
HIRED AUTOS BODILY INJURY
- $
NON-OWNED AUTOS {Per accident}
-
PROPERTY DAMAGE $
{Per accident}
GARAGE LIABILITY AUTO ONL Y - EA ACCIDENT $
==i ANY AUTO OTHER THAN EA ACC $
AUTO ONLY AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ 10000000
A b OCCUR D CLAIMS MADE CK01400765 06/01/05 06/01/06 AGGREGATE $ 10000000
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND X I TORY LIMITS I Iv~:t
A EMPLOYERS' LIABILITY UB8572B552 06/01/05 06/01/06 $ 500000
ANY PRCPRIETORIPARTNERlEXECUTIVE E.L EACH ACCIDENT
OfFICER/MEMBER EXCLUDED? EL DISEASE - EA EMPLOYEE $ 500000
If yes, describe under EL DISEASE - POliCY LIMIT $ 500000
SPECIAL PROVISIONS below
OTHER
B Professional Liab AHC1268760 02/26/05 02/26/06 4000000 Aggregate
2000000 per/occ
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT J SPECIAL PROVISIONS
*except for non-payment of premium. The certificate holder is additional
insured on the general liability policy on a primary and non-contributory
basis with respect to the operations of the above named insured.
CERTIFICATE HOLDER
CANCELLATION
CIDULA3
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIl 30 * DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
City of Dubuque
Ci ty Hall
13th & Central
Dubuque IA 52001
ACORD 25 (2001/08)
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed, A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s}.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s),
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon,
ACORD 25 (2001/08)
. '........ .....''''"'...... ....',--" ,... .........~.".::J'....'.' - ----, ...-......-- . -,,,-, --- --. ----
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8 COMMERCIAL GENERAL LIABILITY PRDnCTION 1IIeftuI
COVERAGE StIIMARY
..
u
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This Coverage Summary shows the limits of
coverag~ that apply to your Commercial
General Liability Protection. It also lists those
endorsements. if any, that must have certain
information thown for them to apply.
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Li.its Of Coverage
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Gull'll tGtal limit
P'.CIS .. cmapltted work
total limit
$
1.000.000
:I:
*
$
1.000.000
/
(I)
~ Personal Injury
~ each persall liRil
$
1,000,000
Il"l
(II
r- Advertising injury
~ each persln I.....
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*
$
$
$
$
1.000.000
Eacll event limil
Premises d1llTJlJf16 limit.
Medical expenses limit.
1,000,000
100,000
5.000
_,I Endor5eIMIIt Table
hnpar" Nots: Only endorsements that must have certain Information shown for them to apply
are named in this table. The required Information follows the name of each such endorsement.
Other endorsements may apply too. If so. they're listed on the Policy Forms List.
Described Person or Organization Endorsement - Addl Prot Persona
Person or Organization ~
Galena-Straus. Hospital & Nur.ing Car Facility ~
215 Su_it
Galena. IL 61036
IE: University of Dubuque - pastorial .tudent. counselling patients.
Person or Organization
J The City-of Dubuque and Dubuque County, including all its elected and appointed
officials, all ita .aploy.e. and volunteers, all its boards, co..issions and/or
authorities and their board ...bers. employees. and volunteers.
v
RE: Han&ars located at the Dubuque Regional Airport
~--- - -
Person or Organization j
Cook College
708 South Lindon Lane
Tempe, AI. 85281
N_ Df I....
UNIVERS ITY OF DUBUQUE
Poliey Nu_.r CK01400765 Effective Date 06/01/04
Processiwg Date 06/22/04 10: 31 001
.(47110 Rev. l-StM>rinted in U.S.A. Coverage Summary
~St.PauJ Fire and Marine Insurance Co. 1996 All Rights Reserved
Page
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any actual or alleged infringement or
violation of any of the following rights or
laws:
. Copyright.
. Patent."
. Trade dress.
. Trade name.
. Trade secret.
. Trademark.
. Other intellectual property rights or laws.
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But we won't apply this exclusion to bodily
Injury or property damage that results from
your products or your completed work.
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Nor will we apply this exclusion to
advertising injury that results from the
unauthorized use of any:
. copyrighted advertising material;
. trademarked slogan; or
. trademarked title;
of othors in your advertising.
In
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We explain the terms your products and
your completed work in the Products and
completed work total limit section.
Liquor 1....llity. We won't cover bodily injury,
property damage, or medical expenses that
result from any protected person:
. causing or contributing to the intoxication
of any person;
. selling, serving, or furnishing alcoholic
beverages to any person under the legal
drinking age or under the influence of
alcohol; or
. violating any law or regulation applying to
the sale, gift, distribution, or use of
alcoholic beverages.
However, we'll apply this exclusion only if
you're in the business of manufacturing,
distributing, selling. serving, or furnishing
alcoholic beverages. For example:
You marvtacture Office equipment. Each
year you host an awards banquet with an
opiin bar for your sales representatives.
After this years banquet an Intoxicated
guest is ifA'oIved in an auto accident. The
guest and several others are injured. If
someone sues you, alleging that your
serving of liquor caused the guests
intoxication and involvement in the accident,
. .......
we wortt apply the .Liquor liability
exclusion because you're not in the business
of serving liquor.
But .we won't apply this exclusion to
premises damage.
We explain the term premises damage in the
Each event limit section.
........1 previoisly ..e bow. Dr usell. We
won't cover personal injury or advertising
injury that results from:
. any material that was first made known
before this agreement begins; or
. any advertising idea or advertising
material, or any slogan or title, of others,
Whose unauthorized use in your advertising
was first -committed before this agreement
begins.
...,I.cal BlpeDS'S Df eertain persons. We won't
cover medical expenses that are incurred by
or for any person:
. injured while qualifying as 8 protected
person, other than your volunte~r workers;
. injured while performing work that he or
she was hired to do for any protected
person, or any tenant of a prC?tected
person;
. Injured on that part of any premises that
you rent or lease from others, or own,
and that the injured person normally
occupies;
. to whom such medical expenses are
payable, or must be provided, as benefits
under any workers compensation law,
disability benefits law, or similar law;
. Injured by your products or your
completed work;
. injured due to war; or
. who refuses to be examined as often as
we require, within reason, by doctors we
choose.
War includes:
. declared or undeclared war, or invasion;
. warlike action by a military force or other
agents of any govemment, sovereign, or
other authority;
. civil war, insurrection, rebellion, revolution,
or seizure of power; or -
. anything done to hinder or defend against
such actions.
47500 Rev. 1-01 Printed in U.S.A. Insuring Agreement
cSt.Paul Fire and Marine Insurance Co. 2001 All Rights Reserved
Page 19 of 27
"........ .....,......-.. .......--., . ,~. --~.".::t'.-... - --.--. .-.--.-..--
..StRlul
Workers compeisation and other ....fits laws.
We won't cover any obligation that the
protected person has under any:
. workers compensation Jaw;
. disability benefits law;
. unemployment compensation law; or
. similar law.
WIOIII prie8 HsalptJel. We won't cover
advertising injury that results from the
wrong description of the price of your
products, your work, or your completed
work.
We explain the terms your products, your
work, and your completed work in the
Products and completed work total limit
sect ion.
Other luur.-ce
This agreement is primary insurance. If
thore is .ny valid and collectible other
Insurance for Injury or damage covered by
this agreement, the following applies in
connection with that other insurance:
Other insurance means Insurance, or the
funding of losses, that's provided by or
through:
. another insurance company;
. us, except under this agreement;
. any of our affiliated insurance companies;
. any risk retention group;
. any self-insurance method or program,
other than eny funded by you and over
which this agreement'applles; or
. any similar risk transfer or risk
management method.
However,we won't consider umbrella
insurance. or excess Insurance, that you
bought specifically to apply In excess of the
limits of coverage that apply under this
agreement to be other Insurance.
Primary II' excess other IDSUrIICI. When there
is Primary other insurance, we'll share with
that other insurance any damages for injury
or damage covered by this agreement. We'll
do so with one of the methods of sharing
described in the Methods of sharing section.
However, we'll apply this agreement as
excess insurance over the part or parts of
any primary or exce.ss other insurance that
provide:
. property or similar coverage for property
damage to your work;
. property or similar coverage for property
damage to premises that you rent, lease,
or borrow from others, other than
premises you rent for a period of seven
or fewer consecutive days;
. aircraft, auto, or watercraft bodily injury
or property damage coverage; or
. protection for you as an additional insured
or additional protected person.
We explain how we'll apply this agreement
as excess insurance in the When this
agreement is excess insurance section.
Aircraft. auto, or wlltercrlJlt bodily injury
or property damage ctNerage means
coverage for bodily injury or property
damage that:
. results from the maintenance, use,
operation, or 10lding or unloading of any
aircraft, auto, or watercraft; and
. isn't specifically excluded by the Aircraft.
Auto. or Watercraft exclusions in this
agreement.
We explain the term your work in the
Products and completed work total limit
section.
WheI dlls agreeRIIll is I.cess IlSurlDc..
When this agreement is excess insurance, we
won't have a dUlY to defend the protected
person against the part or parts of any
claim or suit for which any other insurer has
the duty to defend that protected person.
However, we'll defend the protected person
against a claim or suit for Injury or damage
covered by this agreement if no other
insurer will do so. In return we'll require
that we be given all of that protected
person's rights against each such insurer.
Also, we'll pay only the amount of damages
that's in excess of:
. the total amount that all such other
Insurance would pay if this agreemen~
didn't exist;. and
· the total of all del'Juctible and self-insured
amounts under all such other insurance.
47500 Rev. 1-01 Printed in U.S.A.
Page 26 of 27 .St.Paul Fire and Marine Insurance Co. 2001 All Rights Reserved
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g DESCRIBED PERSON DR ORGANIZATION ENDORSEMENT -
o ADDlnONAL 'PROTECTED PERSONS
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This endorsement changes your Commercial
General Liability Protection.
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i:. How Caveragels a.ge..
8
The following is added to the Who Is Protected
Under This Agreement section. This change
adds certain protected persons and limits their
.. protection.
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Descrlll. per.. or urpniziltiDl. The person or
....
~ organization shown in the Covarage Summary
C') as a described person or organization Is a
protected person. But only for covered Injury
or damage that results from;
.premises you own, rent or lease: or
.your work..
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/43356 Ecl.7-B~rinted in U.S.A.
oSt.Paul Fire and Marine Insurance Co. 1985
We explain what we mean by your worlc In the
Products and completed work total limit
section.
OIlIer Terms
All other terms of your policy remain the same.
Endorsement
Page 1 of 1
".......... ...."....,"".. _,._...... ,n. -.........:::11'.-... - --"-'
or
W
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~ GOVERNMENT PERMIT fOR YOUR WORK ENDOR-.NT -
ADDITIONAL PROTECTSJ PERSIItIS
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This endorsement changes your Commercial
General Liability Protection.
..
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11leSl'Rlul
t:. How Clver. Is Chllge"
8
The following is added to the Who Is Protected
.:.; Under This Agreement section. This change
~ adds certain protected persons end limits their
protection.
:lO
*
Gov.......1t. The state or other unit of
III
~ government shown in the Coverage Summary as
~ a government unit is a protected person. But
~ only for covered injury or damage that results
b from your work for which it has Issued a permit.
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However, the government unit isn't a protected
person for injury or damage that results from
your worle. for it. Nor is it a protected person
for bodily injury or property damage that
results from your completed work.
We explain what we mean by your work and
your completed work in the Products "nd
completed work total limit section.
OIlIer Ter.
All other terms of your policy remain the same.
Page 1 of 1
143342 Ed.7-8~rinted in U.S.A.
oSt.Paul Fire and Marine Insurance Co.1985
Endorsement
I '....'.,. '''''~'''''' .......1~" '0'. --....."..:::f........ - __.._. 0"__'_"--
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City of Dubuque-& Dubuque County
Cancellation and Material Changes Endorsement
This endorsement chances your Commercial Ceneral Liability Protection.
~
o
o
.. How Coverage Is Changed:
iJI Thirty (30) days' Advanced Written Notice of Cancellation. Non-Renewal.
Reduetion in insurance coverage or limits and or material change by endorsement
M and ten (10) days written notice oi non-payaent of premium shall be sent to:
~ Engineering Division, City Hall, 50 West 13th Street, Dubuque. IA 52001-4864.
This end~rsement supersede. the standard cancellation statement on the
~ Certificate of Insurance to which this endorsement is attached.
.
~ City of Dubuque & Dubuque County. City Hall. 13th & Central. Dubuque. IA 52001 _ ~
~ Additional Insured Endorsement ~
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the City of Dubuque. Iowa. including all its elected an4 appointed officials.
all it. eeployees and volunteers. all it. boards, co..iasions and/or
authorities and their board .embers. eaployees. and volunteers. are included
as Additional Insureds with respect to all work and services performed for the
City of Dubuque, Iowa. This coverage shall be primary to the Additional
Insureds. and not contributing with any other insurance or similar protection
available to the Additional Insureds_ whether other available coverRle be
priaary_ contributing or excess.
City of Dubu~ue & Dubuque County, City Hall, 13th & Central_ Dubuque. IA 52001
Governmental I..unities Endorsement
1. Non-Waiver of Government I__unity, The insurance carrier expressly agrees
that the purcha.e of this policy and the including of the City of Dubuque.
Iowa as an Additional Insured does not waive any of the defenses of
governaental immunity available to the City of Dubuque. Iowa under Code of
Iowa Section 670.4 .s it now exist. and .s it be amended fro. time to tiae,
2. Clai.s Coverage. The insuranee carrier further acrees that this policy of
insurance shall cover only those claiaa not subjeet to the defense of
soverumenta1 immunity under the Code of Iowa Section 670.4 as it now exists
and as it may be amended from time to time, Those clai.. not subjeet to Code
of Iowa Section 670.4 shall be covered by the teras and conditions of this
insurance policy.
3. Assertion of Government I__unity. The City of Dubuque, Iowa shall be
responsible for asserting any defense of governmental i..unity. and .ay be so
at any time and shall do so upon the ti.ely written request of the insurance
carrier.
4. Non-Denial of Covera,e. The insurance carrier shall not deny coverage under
this policy and the insurance carrier shall not deny any of the rights and
benefits accruing to the City of Dubuque, Iowa under this pOlicy for reasons
of govern.ental i..unity unle.. and until a court of competent jurisdiction
has ruled in favor of the defense (8) of govern.ental i_unity asserted by the
City of Dubuque, Iowa
5. No other Change In Policy. The insurance carrier and the City of Dubuque
agree that the above preservation of governmental i..unities shall not
,... at Ilsured tJt~ Policy NIIIIber CX01400765 Effective Date 06/01/04
UNIVERSITY OF DUBUQUE )~I Processing Date 06/22/04 10:31 001
/40502 Ed.l-aoJ.rinted in U.S.A. Customized Form
sSt.Paul Fire and Marine Insurance Co. 1980 All Rights Reserved Page
rlVUI. '''t~IC;11 ,"",1~1l rHo .....\.oo'UII.~'.Col'.'... ................ ...-....,- . .....~._. ........... ....-. ----
1IIe.....
otherwise change or alter the coverage available -under the policy.
Other Terms:
.
All other teras of your policy remain the same.
Page 2
cSt.Paul Fire and Marine Insurance Co.1980 All Rights Reserved