Student Acknowledgement Agreement Template - Dalhousie University printable pdf download

Student Acknowledgement Agreement Template - Dalhousie University

Appendix A

(Name of Student)

with respect to a placement at

Agency Name (the “Agency”)

through

Dalhousie University on behalf of the

School of Social Work

STUDENT AKNOWLEDGEMENT

The Agency and the University have signed an Agreement about the placement programs

in which you wish to participate. Prior to starting a placement in the Agency you are

required to read and sign this Acknowledgement. This document describes your

responsibilities during your placement and other important information you should know.

By signing this Acknowledgement, the undersigned agrees to the following:

1. Placement programs cannot compromise the client/patient care or client service

objectives of the Agency. Agency staff is the final authority for all aspects of

client/patient care or client service and for the integration of the placement programs

into the Agency.

2. The Agency has the right to require me to leave the Agency’s facilities or programs

because of my performance or conduct. This right will not be exercised without prior

discussion with the appropriate School or College except in extraordinary

circumstances.

3. I am aware of my responsibility to maintain appropriate behaviour while in the

Agency’s facilities and programs, particularly concerning patients’/clients’ privacy

and confidentiality of patients’/clients’ records and all other Agency related

information and matters. All such information is confidential and cannot be

communicated except as outlined in the Agency policy. I will not disclose what I see

or hear, or pass on information from written records concerning any client/patient,

except for the purposes of client/patient care or service. I will not discuss

patients/clients publicly, either within or outside the Agency. If confidentiality is

breached, the penalty may include termination of my placement.

Student Acknowledgement Agreement Template - Dalhousie University