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Policy and Procedure ManualChapter 210, Instruction A request for an affiliation agreement should include the information below. Separate forms are available for affiliation agreement requests from School of Medicine departments and from UCDMC departments and Primary Care Network (PCN) clinics. For the School of Medicine form, contact the Dean's Office. The form for UCDMC and PCN units is available in UCDHS Policies and Procedures Manual Section 2912. 1. The identity of the departments that will benefit from the affiliation, a description of the benefits and their relationship to the University's mission, and the reason that these benefits are not available within the University's facilities or through existing affiliations. 2. The identity, including legal name and status (e.g., for- profit, not-for-profit, corporate, public agency) of the proposed affiliate, the program for which the affiliation is required, and the address of the facility at which training/ educational activity under the affiliation agreement will occur. 3. A description of the training/educational activity of the proposed trainees (e.g., undergraduate students, graduate students, medical students, postgraduate medical trainees) and of the direct supervisors of the trainees. 4. The University's and the proposed affiliate's separate responsibilities. 5. The University's and the proposed affiliate's joint responsibilities. 6. Whether or not the agreement will carry any financial obligations and, if so, definition of those financial obligations. 7. Names, addresses, and telephone numbers of contact persons at the proposed affiliate. 8. Any additional background information that may assist the Business Contracts Office in facilitating agreement through knowledgeable discussion with the proposed affiliate. 9. The approving signature of the dean, vice chancellor, or UCDHS administrators to whom the department reports. Copyright © 2006 The Regents of the
University of California, Davis Campus. All Rights Reserved. |
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