SHORT-TERM EDUCATION PROGRAM

TERMS OF APPOINTMENT

NAME OF PARTICIPANT:

Estefania Pena Lopez

_______________________________________________________________
[Please Print]

I understand, agree and acknowledge that for purposes of an appointment to the Short-Term Education Program
(STEP Program), my role will be that of an observer only. An observer is defined in the strictest sense as
someone who watches and listens only with no patient care provided and no research activity. As a STEP
Program participant, I understand that I am able to attend Grand Rounds, observe attending physicians, and
participate in conferences, teaching seminars, or other educational activities. This appointment is undertaken by
me solely for the purposes of gaining knowledge to be utilized in my career or professional development, and I
further understand that I will have no access to clinical systems, no compensation, no fringe benefits, no
educational credit, and no employment relationship with MD Anderson in connection with this appointment.
I understand, agree and acknowledge the following requirements apply to my participation in the STEP Program:
1) I acknowledge that I am subject to the policies, rules, and regulations of The University of Texas MD
Anderson Cancer Center (MD Anderson) and the Board of Regents of The University of Texas System
(Board) in connection with my participation in the STEP Program.
2) I will not receive any academic credit or an educational certificate for this experience, and I will not be
considered a student, resident, fellow, rotator or trainee of the hosting department at MD Anderson. A
verification of appointment is available upon request. I further understand that this appointment will not
apply towards elective credit or transcripts for completion of educational programs (i.e., clinical schools,
residencies, or fellowships).
3) I will not be permitted to provide any direct patient care and may not perform any patient services which
includes, but is not limited to, performing the following functions: taking medical history, performing
physical examination, diagnosing and treating patients condition, prescribing and administering drugs,
writing notes or orders in patients chart, performing and assisting in a procedure, or billing for services
rendered. I acknowledge that providing medical care to patients in violation of these Terms of
Appointment may result in civil liability, licensing sanctions and criminal penalties.
4) I will not be permitted to engage in research activity involving a research laboratory, research protocol, or
a research project/paper.
5) I will not be considered an employee or staff member of MD Anderson and will not be entitled to salary,
benefits, reimbursement of expenses or other compensation.
6) I understand that I must be accompanied by the hosting faculty or a department representative
throughout this appointment. I further understand that I must also be accompanied by an MD Anderson
attending physician when observing patient care activities. I will have no access to computer systems,
patients or patient records (e.g., Clinic Station, other clinical information systems or hard copies of clinical
records).
7) I agree to wear an ID badge provided by AVA-TAA prior to entering the hosting department. The badge
will display the title of Short-Term Education Program and must be returned to the hosting
departments Department Administrator at the end of the assigned days of observation.

8) I attest to having had a health status assessment as outlined by the Certificate of Health Statement, as
part of my application, which complies with all applicable MD Anderson policies, rules and regulations, as
would otherwise be evidenced by a completed Immunization Form and applicable reports. I agree to
refrain from patient care observation at any time that I have an infectious disease or condition that could
be transmitted to patients.
9) I understand that MD Anderson, the faculty host, or I may terminate this appointment at any time and for
any reason prior to the scheduled conclusion of the appointment by providing written or oral notice to
the other party. I acknowledge that there is no grievance, appeal or other due process procedures
available to challenge the termination of an appointment to the STEP Program.
10) I acknowledge that I may have access to confidential and/or proprietary information of MD Anderson
(Confidential Information), and that this Confidential Information is not subject to disclosure under the
Texas Public Information Act. I agree that I will not use or disclose MD Andersons Confidential
Information or publish any writing relating to my experience at MD Anderson without MD Andersons
prior written approval.
11) I agree that any intellectual property, whether or not patentable, that: (a) results from my participation in
the STEP Program; (b) results from activities performed during the STEP Program or with support or use of
State funds or facilities, such as MD Anderson; or (c) comes from MD Anderson or The University of Texas
System research supported by a private or public grant, gift, or contract is subject to ownership by MD
Anderson and/or the Board. I further agree that I will report any such intellectual property to MD
Anderson prior to disclosure at any time, so that MD Anderson and/or the Board can take the appropriate
steps to protect it and commercialize it.
12) I have reviewed the handout entitled Protecting Patient Privacy. I understand that I have an obligation
to protect patient privacy by permanently maintaining the confidentiality of all protected health
information (PHI) that I may be exposed to at MD Anderson, including the fact that someone is an MD
Anderson patient.
13) I agree not to photograph or record any patients, procedures, or patient information while at MD
Anderson.

I have read and understand the terms of the STEP Program appointment:
STEP Program Participant

_________________________________
(Signature)

Estefania Pena Lopez

_________________________________
(Printed or type name)

03/12/2015
Date: ____________________________

Revised September 2014