Dear Deans, Directors and Chairs,

Please find the following five forms developed by General Counsel to be used in relation to clinical and non-clinical placements for UVM students:

31113 – Clinical site letter and acknowledgement

31198 – Non-clinical site letter and acknowledgement

31109 – Student checklist for CNHS clinical placements

31016 – Student checklist for non-clinical placements

31255 – Student checklist for LCOM clinical placements

These forms have been developed for the purpose of ensuring that clinical and non-clinical placement sites are aware of, and agree to abide, by UVM’s health and safety standards, and that UVM students attest to their willingness to comply with the standards established by UVM as well as in their clinical and non-clinical sites. 

In addition to the forms, existing and new affiliation agreements need to include similar language around adherence to UVM Health and Safety standards. 

We ask that you assist in ensuring our student's health and safety by completing the following steps as appropriate to your area:

  • Clinical and non-clinical site letter and acknowledgements: For those sites with an agreement already in place, please choose and send the appropriate letter to each of your off-campus partners. Signed acknowledgments must be returned to your Dean’s Office prior to students engaging in placements. Dean’s Offices are responsible for monitoring completion of all forms and sending them to General Counsel to be kept on file.
  • Student checklists (CNHS clinical placements, LCOM Clinical Placements, and Non-Clinical Placements): Each unit is responsible for ensuring that students placed at off-campus clinical or non-clinical sites sign the appropriate form. This may be done remotely or during orientation sessions in which you prepare students for their placements. Completed forms must be kept on file in your Department or Dean’s Office, in accordance with existing practices around files for students in field placements.
  • Affiliation agreements: For any sites with whom you are newly executing or renewing agreements, standard health and safety language will need to be included. 

Units with template agreements (clinical and other) should send them to Katie Beneke in the General Counsel Office ( She will assist units with amending their template agreements to include standard COVID language. Appropriate language will be added toany new third-party agreements as part of the typical review and execution process by the Office of General Counsel. If your unit receives communications from partner sites that requests procedures not covered under UVM’s health and safety guidelines (e.g., requests for different testing protocols), please forward those requests to Katie Beneke in General Counsel.


William Falls, Dean, College of Arts & Science