Mount Nittany Health (“Mount Nittany”) STUDENT AGREEMENT OF RESPONSIBILITY
This document contains a statement of responsibilities to be assumed by the student during the internship/clinical experience. The student is required to sign Mount Nittany’s STUDENT AGREEMENT OF RESPONSIBILITY, which includes an Oath of Confidentiality, prior to activity at Mount Nittany. The internship/clinical experience is governed by an Educational Affiliation Agreement between Mount Nittany Health and the institution. This Statement of Responsibility is prepared in accordance with that Agreement.
 Definitions:	
Faculty Member -- Employee/faculty of the school who directly supervises the student’s educational experience. Preceptor – Mount Nittany employee who guides and directs a student’s internship/clinical experience.
Mount Nittany Health  (“Mount Nittany”) – Mount Nittany Medical Center, Mount Nittany Health Surgical Center, Mount Nittany Physician Group, Mount Nittany Health Foundation, Children’s Advocacy Center of Centre County, and the Cancer Care Partnership (“CCP”), individually and collectively.
 The Student:	
1.	Agrees to work under the direct supervision of the Preceptor or the school’s Faculty member during internship/clinical hours.
2.	Agrees to conform to Mount Nittany’s dress code.
3.	Agrees to assume responsibility for the completion of all internship/clinical assignments, such as written reports, required by the school.
4.	Observes Mount Nittany policies and procedures during the internship/clinical experience.
5.	Agrees to comply with the health requirements as stated in Infection Control Policy 407, Health Policy: Students, Faculty and Contracted Patient Care Providers.
6.	Adheres to scheduled hours and reports any absence promptly to the Preceptor/Faculty member. The student assumes the responsibility for making up the time missed through illness or family emergency.
7.	Agrees, if appropriate, to maintain current professional liability insurance policy at limits indicated in the educational affiliation agreement.
8.	Agrees to report any alleged, charged, or resolved ongoing incidents of criminal conduct to Mount Nittany.
9.	Agrees to report any medication(s) the student is currently taking that may have the potential to impair judgment and/or the ability to perform duties as required/expected such as: narcotics, anti-depressants, sedative-hypnotics, anti-convulsants, anti-psychotics, controlled substances, medical marijuana and any other drug classifications that Professional and Organizational Development deems appropriate.  To the extent that the student discloses any such medications, the student also agrees to execute a Medication Use Agreement in a form acceptable to Mount Nittany.

Oath of Confidentiality: I agree as a condition of my internship/clinical experience to treat all proprietary information relating to the business and operation of Mount Nittany, information about individuals whom I encounter, all patient information available through any source, and all other information available to me through records and documents during my internship/clinical experience at Mount Nittany in strictest confidence and keep the information, names and other forms of identities anonymous and I further agree that the information available to me will be used only for the purpose of my study/research/academic work. I understand that a violation of this confidentiality agreement by me may result in my suspension from the internship/clinical experience at Mount Nittany and my breach of confidentiality will be reported to the agency/institution that I represent. Further, I understand that I may be subject to legal action for violation of this confidentiality agreement.

Release of Liability and Responsibility for Medical Care: I have reviewed important safety and customer service information provided to me and have had an opportunity to have questions answered about the information. I acknowledge that my internship/clinical experience at Mount Nittany may involve observation of health care patient treatment and I hereby agree to release Mount Nittany from any and all claims for injuries occurring to me as a result of my reaction (i.e. fainting, nausea, etc.) to the observation of health care patient treatment.

I understand that I am fully responsible for arranging and paying for any and all medical care and/or treatment (including transportation) required during my participation in the program.  Accordingly, I agree that I will maintain, without interruption during my participation in the program, coverage under a personal medical insurance plan and will provide proof of such coverage to Mount Nittany upon request.  I understand that I am not an employee of Mount Nittany and in no event will Mount Nittany be responsible, financially or otherwise, for any medical care or treatment that I receive.

My signature below represents my agreement to be legally bound by the terms of this Agreement set forth above.

Student (print name):	___________________________________________________________________________

School:			___________________________________________________________________________

Field of Study:		___________________________________________________________________________

Internship/Clinical Dates:	___________________________________________________________________________

Signature:			__________________________________________________  Date: ___________________

Parent/Guardian Signature:	__________________________________________________  Date: ___________________
(for student under age 18)
Revised 4/12/24