UNIVERSIDAD DE ZAMBOANGA

Zamboanga City
STUDENT INTERNSHIP AGREEMENT
Academic Year 2022-2023

Known All Men By These Presents:

This agreement with a student on LABORATORY/HOSPITAL internship training executed this

_____________________ in Pagadian City, Philippines by and among:

UNIVERSIDAD DE ZAMBOANGA - PAGADIAN BRANCH

-and-

(Student)

The parties hereby agree to the following terms and conditions:

1. The student must complete the internship training with the specified time agreed upon with the school.
2. The intern shall undergo medical examinations and vaccinations as required by CHED/hospital and
school (X-Ray, CBC, Urinalysis, Fecalysis, Drug Test, Hepa Titer, RT PCR/Antigen Test - if required,
Hepa vaccine, COVID-19 vaccine, Pneumococcal vaccine).
3. The student must not get involved/join in any subversive organization that will destroy the name of the
school.
4. In case of sickness or “Force Majeure” conditions preventing the completion of the internship training, a
justification to be accompanied by pertinent documents must be presented to the school subject for
thorough evaluation.
5. The student must not incur any unpaid obligations during the duration of the internship training. The
school has the right to charge the student additional fees for any unpaid obligations such as board and
lodging and other debts incurred with any hospital personnel or institutions he/she has directly or
indirectly dealt with during the internship program.
6. The school may endorse the students to a dormitory/boarding house located outside Zamboanga City for
his/her stay during the entire duration of the internship. In case of transfer of location, the student should
write a justification letter to the Dean/Director duly signed by their parent/guardians and the university
shall not be held liable for the safety and security of the student.
7. The school has the sole right to select the student’s hospital rotation conforming to the internship
guidelines and memoranda of agreement set by the hospital affiliates.
8. Should the student request for a voluntary pull-out, the student must submit a justification letter to be
accompanied by pertinent documents duly signed by his/her parents. The student who requested for
pull-out shall have his/her completion of hospital exposure the next endorsement and shall pay again the
internship fee and other necessary fees. The previous number of hours/month/s completed shall be
considered null and void.
9. The student for internship shall wear the prescribed hospital uniform. Only white head veils for females
are allowed. Niqab is strictly not allowed. A modification of the hospital uniform of any kind is not
allowed. No jewelry allowed for student interns except for wrist watches with second hand; wedding
rings for married students. If the student violates, she will not be allowed to render the hospital duty.
10. Male students for internship are required to observe proper haircut and shave any beard or mustache
before hospital deployment. If the student violates, he will not be allowed to render the hospital duty.
11. Courtesy and respect must be demonstrated at all times. Call/address instructors, personnel and peers by
his/her family name and the appropriate title. Shouting or loud voices or the use of vulgar language is
neither allowed nor tolerated.
12. Eating and drinking in the patient’s room and within the laboratory is not allowed.
13. Soliciting favors, gifts and donations from staff, patients and/or relatives is not permissible and shall be
subjected to disciplinary actions
14. Any form of intimate relationship between employees and interns is strongly discouraged and should be
avoided.
15. The student must not engage in any forms of activities such as night or day social drinking in their
boarding house/dormitory/any private or public place, going to disco house/club/bar, smoking and any
other unnecessary activities with any of the hospital staff/peer/any person. Any violation stipulated above
 he/she shall undergo 2 months extension of duty/or be given other tasks as determined by the
college/department and will pay the additional amount set by the hospital for the extension of duty.
16. The student is not allowed to go on trips such as tourist destinations within and outside Cagayan de Oro
City/Ozamis City/Zamboanga City during the entire internship duration. Any violation stipulated above
he/she shall undergo 1 ½ month extension of duty/or be given other tasks as determined by the
college/department and will pay the additional amount set by the hospital for the extension of duty.
17. Unauthorized trips outside the premises of the training locations without clearance and prior notice from
internship coordinator and the department shall be issued a 5 – day extension of duty per incident.
18. The interns are required to attend the review class/seminar class regularly thru online platform.
19. Failure to report on scheduled extension of duty means additional demerits/ extension of duty hours.
20. Students with demerits or extensions of duty hours not beyond 100 hours and incurred in the 1st
semester/2nd semester can be promoted to the next level provided it must be worked out during summer
of the current school year in the Medical Technology Program.
21. In extreme cases, as when the student incurs more than 100 hours of demerits and cannot be finished in
summer time, the completion/ payment of demerits can be done during holiday season. Only if and when
the Clinical Instructor/s is/are available, and with the approval of the hospital where the extension works
out is to be done.
22. The student submits a letter of Request for Extension work out to the Dean. If/when approved, the student
can work with the C.I. assigned to supervise the duty. Payment of extension is made to the Clinical
Instructor according to her/ his hourly rate. Demerits can be worked out during Saturdays/Sundays if the
Clinical Instructor is available.
23. The students should pass the exams of seminar and revalida/pre-board exam. If the student fails to pass
the examinations, his/her endorsement for graduation shall be put on hold pending the passing remarks in
the revalida.
24. Interns who fraudulently negotiate for special duty schedules shall be removed from the program.
25. All types of electronic gadgets are not allowed during duty hours (cell phones must be put off or on silent
mode).
26. The students for internship shall strictly abide by the internship rules and regulations of Universidad de
Zamboanga and the hospital institution.
27. In case that the student gets infected with COVID19, he/she shall shoulder any COVID -19 related
expenses to include but not limited to Reverse Transcription-Polymerase Chain Reaction (RT-PCR) Test
or Antigen Test, hospitalization, quarantine, and others.
28. The student shall provide the necessary documents and clearances in cases of hospitalization due to
COVID -19 or coming from self-isolation or quarantine facility as closed contact to a positive COVID
-19 patient before resumption of duty.
29. The student shall strictly adhere to the alert level protocols by the National IATF and Local Government
Unit. Onsite internship deployment shall be fluid depending on the quarantine level of the LGU where the
student intern is deployed. Students deployed for internship at which the Alert Level is upgraded to level
four (4) shall automatically be suspended. Student interns shall remain in their designated dormitories
until official announcement for the resumption of onsite internship will be given by duly authorized
person (Clinical Instructor/College Dean/Director), and thereby attend online internship programs.
30. The student shall follow the scheduled trip from the internship area going back to the University. If the
student insists on going back outside of the approved schedule, the university shall not be held liable for
the safety, security, and expenses incurred due to this. Prior to the unscheduled trip, the student shall write
a justification letter duly signed by their parents/guardians and subject to the approval of the Dean.
31. Should the intern become physically, mentally or emotionally incapable of carrying out his/her duty as an
intern, the training institution and the department reserve every right to impose intern withdrawal and
suspension from duty upon thorough evaluation.
32. All extension duties and/or make – up duties shall be served at the end of each rotation.
33. At the end of the internship program, interns must duly submit fully filled out manuals, narrative reports,
graded evaluation forms and internship certificates from the different training centers as proof of
completion.

DUTIES AND RESPONSIBILITIES OF INTERNS:

1. Proper Decorum
The intern shall:
a. Behave professionally at all times
b. Serves the patients with compassion
c. Avoid undue familiarity and intimacy with patients and staff
d. Handle patient information with utmost confidentiality
e. Work harmoniously with fellow interns and other personnel of the institution.
2. Attendance and punctuality
a. The intern shall adhere strictly to the policies of the institution and training center on absences and
tardiness.
3. Laboratory Breakages
 a. The intern shall be solely responsible for the payment, replacement or repair of laboratory equipment
and/or supplies incurred by them.
4. Confidentiality and Non-disclosure
a. The intern shall strictly observe the confidentiality and non-disclosure policies pursuant to Data Privacy
Act. Any breach in the hospital/laboratory policy on data privacy shall render the student liable.
5. Adherence to Internship Area Policy
a. Students shall ensure that all policies and guidelines of the internship by the university and partner
institution as internship area should be strictly adhered to.

OFFENSES AND SANCTIONS:

ABSENCES
1. Absence due to sickness w/ medical certificate - 1: 8 hours
2. Absence due to sickness w/o med. Certificate - 1: 16 hours
3. Absence without notice - 1: 24 hours
4. Absence due to death of immediate relatives - 1: 8 hours
5. Absence due to death of non-immediate relatives - 1:16 hours
6. Absence from scheduled demo/ return demo/orientation ward classes/ bedside clinic/ conferences - 1:8 hours
7. Absence due to sickness of immediate relatives - 1: 8 hours
8. Absence due to failure to come home from holidays/ vacation - 1: 16 hours

TARDINESS
1 – 15 minutes late - 4 hours
16 - 30 minutes late - 8 hours
30 - 60 minutes late - 16 hours
More than an hour - considered absent without notice and should complete 24 hours extension

NEGLIGENCE/ MISCONDUCT
1. Incorrect entry/ reporting & recording in patient’s chart / client’s record
❖ 4 hours
2. Inadequate knowledge indicating lack of preparation; not following instructions from C.I
(Failure to assess client prior to duty; failure to join in the Nursing rounds; failure to monitor client’s status)
❖ 1st offense : 8 hours
❖ 2nd offense : 16 hours
2. Treatment/Medication Error (wrong medication; failure to perform the expected intervention/procedure)
❖ 1st offense : 8 hours
❖ 2nd offense : 16 hours
❖ 3rd offense : 24 hours
3. Non-submission of requirements (Assessment, drug study, NCP, clinical notebook, case studies, clinical
readings)
❖ 16 hours
4. Late/incomplete submission of requirements (Assessment, drug study, NCP, clinical notebook, case studies,
clinical readings)
❖ 8 hours
5. Doing of requirements in the area of assignment (Daily objectives, assessment, drug study, NCP, clinical
notebook, case studies, clinical readings)
❖ 8 hours
6. Absence during the orientation (OR, DR)
❖ No orientation, no duty, no swapping of areas
7. Late during the orientation (OR, DR)
❖ 8 hours
8. Late during endorsement
❖ 4 hours
9. Sleeping while on duty
❖ 24 hours
10. Leaving the clinical area/patient without proper endorsement / permission from the C.I.
❖ 24 hours
11. Forgery of the signatures of C.I. / Staff
❖ 24 hours
12. Incomplete uniform / wearing of prescribed uniform
❖ 8 hours
13. Incomplete / borrowing paraphernalia
❖ 4 hours
14. Failure to do after care in the work area
❖ 4 hours
15. Disrespect to school/hospital authorities (defiance of instructions, shouting along the lobby/corridors,
smoking, littering, vandalism, use of indecent & vulgar language, spitting on the floor, discussion of confidential
matters pertaining to the patient).
❖ 30 hours
16. Dishonesty (fraud, sharing of stool specimen)
❖ 30 hours
17. Unauthorized use of gadgets (cellphones, tablets, laptops, etc.) during duty hours.
❖ 8 hours
18. Retrieval of original medical result from the level coordinator
❖ 4 hours
29. Failure to submit clearance from previous rotation by the second day of duty
❖ 8 hours
30. Lost clearance
❖ 8 hours

❖ Sanctions shall be determined by the training center, college and the institution on the following:
● Cheating and dishonesty in any form (forgery, falsification of documents, etc.)
1. Alcohol intoxication
2. Inflicting physical injury
3. Carrying of deadly weapon
4. Possession and/or use of prohibited drugs
5. Sexual harassment
6. Vandalism
7. Gambling
8. Stealing
9. Immorality
10. Wilful destruction of hospital property
11. Cyberbullying
12. Blackmailing

Other violations are subject to school policy and school – issued internship manuals.

________________________________________ __________________________________________
Parents Full Name and Signature Parents Full Name and Signature

Signed in the presence of:

MARICHU CAZEL A. SARA, CMT, RN, MN ENBER B. PACHECO, MAGC, RGC

OIC - Dean of Nursing Department, UZ Pagadian Director, Department of Student Affairs and Services

EDUARDO D. DANDA, RMT, MSMT

School Administrator, UZ Pagadian

Conforme: