Common use of Agreement Review Clause in Contracts

Agreement Review. This agreement will be automatically reviewed every three years through a process initiated by the Vancouver Coastal Health Authority. Parties to this agreement may request a review at any time. Availability of resources or breakdown in processes are examples of areas that may trigger a need for review Vancouver Coastal Health Region Schedule 1 - School Districts Within Vancouver Coastal Health Region School District #38, Richmond School District #39, Vancouver School District #44, North Vancouver School District #45, West Vancouver School District #46, Sunshine Coast School District #47, Xxxxxx River School District #48, Xxxx Sound Procedural Responsibilities Vancouver Coastal Health Region for Delivering Assistive Listening Technology to School Aged Children and Youth Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  Carry out assessment and diagnostic services  Get parental approval for audiogram release and report to the school district and PRP  Health Authority Information Form Release  PRP provides Permission to Share Form  Collaboration between health unit audiologist and school district personnel regarding classroom environment and support available in school, which may influence the decision regarding the most appropriate assistive listening equipment required to maximize learning.  Determine appropriate channel, including default channel if required.  Determine most appropriate FM from PRP list of available equipment  Inform family and provide PRP Permission to Share information form for parent signature PRP Permission to Share form  Share information with audiologist or technician regarding school and classroom environments, identifying problem areas (e.g. gym—reverberation, possible interference)  Identify competencies needed to support equipment  Specify who will provide any required in- service.  Provide list of available equipment to all health units, school districts and group 1 and group 2 independent schools  Loan Bank Equipment List  Indicate FM being requested and sign the request form, signaling responsibility for appropriate equipment selection for the student  Send FM request form, along with audiological information and Permission to Share form to school district for school district administrator signature (except Vancouver Clinic)  FM Request form  Complete Permission to Share form if not completed at Health Unit  Complete and Sign FM request form agreeing to accept financial liability for lost/damaged equipment (district administrator)  Provide FM request for support form via Website  Provide Permission to Share form via Website  Request for Support Form  Parent Permission to Share form Vancouver health unit only:  Forward signed forms along with audiological information to PRP  Send copy of FM request form to school district  Place copy of signed FM request form in the child’s health unit file  Forward signed forms along with audiological information to PRP  Send copy of FM request form to health unit and e-mail when sent to PRP  Update student’s confidential file  Receive complete Request for Support package  Communicate with health unit audiologist if equipment is not available or clarification required  Discuss options with audiologist and HRT responsible for the student in the district, if required  Repair form Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  Receive equipment, e-mail confirmation of receipt of shipment to PRP and School District, and complete listening validation  Record in child’s file Send equipment to health unit along with equipment service report or packing slip. E-mail health unit and SD about shipment, or if delays anticipated  Complete FM/HA equipment verification in accordance with best practice, i.e. eletroacoustic FM match with child’s personal hearing aid  Record in child’s file with appropriate documentation  Arrange for equipment to be sent to student’s HRT and provide training and/or written material for the use of the equipment and troubleshooting.  Record when equipment leaves the clinic.  Pick up equipment at the health unit or receive equipment at a designated location.  Keep note of serial numbered equipment on loan  On request, provide printout of district equipment currently on loan.  Provide training and/or written material to school staff if health unit unable to provide.  Equipment validation needs to be conducted by personnel trained to do listening checks.  Ensure school principal is aware of the equipment and that security measures are in place.  District protocol for equipment security  Provide ongoing maintenance and equipment checks (e.g. regular listening check, purchase of batteries for the FM and cords as required – School District responsibility to purchase items.)  Validate and document the benefit to student (e.g. functional listening evaluation, teacher questionnaires, etc.) and seek audiologist’s advice if problems, concerns arise.  Return malfunctioning equipment to PRP or health unit for repair or replacement.  Use Request for Repair form or Equipment Return form provided by PRP.  Return malfunctioning equipment to PRP or health unit for repair or replacement.  Use Request for Repair form or Equipment Return Form provided by PRP.  Notify PRP and clinic by email equipment was sent.  Receive malfunctioning equipment and process repair.  Courier repaired or replaced equipment on following working day to health unit audiologist or school district as requested.  Request to Repair form  Equipment Return form

Agreement Review. This agreement will be automatically reviewed every three years through a process initiated by the Vancouver Coastal Health Authorityyears. Parties to this agreement may request a review at any time. Availability of resources or breakdown in processes are examples of areas that may trigger a need for review Vancouver Coastal Fraser Health Region Schedule 1 - School Districts Within Vancouver Coastal Fraser Health Region School District #3833, Richmond Chilliwack School District #3934, Vancouver Abbotsford School District #4435, North Vancouver Xxxxxxx School District #4536, West Vancouver Surrey School District #4637, Sunshine Coast Delta School District #4740, Xxxxxx River New Westminster School District #4841, Xxxx Sound Burnaby School District #42, Maple Ridge-Pitt Xxxxxxx School District #43, Coquitlam School District #75, Mission School District #78, Fraser-Cascade Procedural Responsibilities Vancouver Coastal Fraser Health Region for Delivering Assistive Listening Technology to School Aged Children and Youth Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  ⮚ Carry out assessment and diagnostic services  ⮚ Get parental approval for audiogram release and report to the school district and PRP  ⮚ Health Authority Information Form Release  ⮚ PRP Permission to Share form ⮚ PRP provides Permission to Share Form  ⮚ Collaboration between health unit audiologist and school district personnel regarding classroom environment and support available in school, which may influence the decision regarding the most appropriate assistive listening equipment required to maximize learning.  ⮚ Determine appropriate channel, including default channel if required.  ⮚ Determine most appropriate FM from PRP list of available equipment  ⮚ Inform family and provide PRP Permission to Share information form for parent signature PRP Permission to Share form  ⮚ Share information with audiologist or technician regarding school and classroom environments, identifying problem areas (e.g. gym—reverberation, possible interference)  ⮚ Identify competencies needed to support equipment  ⮚ Specify who will provide any required in- service.  ⮚ Provide list of available equipment to all health units, school districts and group 1 and group 2 independent schools  ⮚ Loan Bank Equipment List  ⮚ Indicate FM being requested and sign the request form, signaling responsibility for appropriate equipment selection for the student  ⮚ Send FM request form, along with audiological information and Permission to Share form to school district for school district administrator signature (except Vancouver Clinic)  ⮚ FM Request form  Complete Permission to Share form if not completed at Health Unit  ⮚ Complete and Sign FM request form agreeing to accept financial liability for lost/damaged equipment (district administrator)  ⮚ Provide FM request for support form via Website  ⮚ Provide Permission to Share form via Website  ⮚ Request for Support Form  ⮚ Parent Permission to Share form Vancouver health unit only:  ⮚ Forward signed forms along with audiological information to PRP  Send copy of FM request form to school district  Place copy of signed FM request form in the child’s health unit file  Forward signed forms along with audiological information to PRP  ⮚ Send copy of FM request form to health unit and e-mail when sent to PRP  Update student’s confidential file  ⮚ Receive complete Request request for Support package  ⮚ Communicate with health unit audiologist if equipment is not available or clarification required  ⮚ Discuss options with audiologist and HRT responsible for the student in the district, if required  ⮚ Place copy of signed FM request form in the child’s health unit file ⮚ Update student’s confidential file ⮚ Send equipment to health unit along with equipment service report or packing slip. ⮚ E-mail health unit and SD, it has been shipped or if delays anticipated ⮚ Repair form Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  ⮚ Receive equipment, e-mail confirmation of receipt of shipment to PRP and School District, and complete listening validation  ⮚Record in child’s file Send equipment to health unit along with equipment service report or packing slip. E-mail health unit and SD about shipment, or if delays anticipated  ⮚ Complete FM/HA equipment verification in accordance with best practice, i.e. eletroacoustic FM match with child’s personal hearing aid  ⮚ Record in child’s file with appropriate documentation  ⮚Arrange for equipment to be sent to student’s HRT and provide training and/or written material for the use of the equipment and troubleshooting.  ⮚ Record when equipment leaves the clinic.  ⮚Pick up equipment at the health unit or receive equipment at a designated location.  ⮚Keep note of serial numbered equipment on loan  ⮚On request, provide printout of district equipment currently on loan.  Provide training and/or written material to school staff if health unit unable to provide.  ⮚ Equipment validation needs to be conducted by personnel trained to do listening checks.  ⮚ Ensure school principal is aware of the equipment and that security measures are in place.  ⮚District protocol for equipment security  ⮚ Provide ongoing maintenance and equipment checks (e.g. regular listening check, purchase of batteries for the FM and cords as required – School District responsibility to purchase items.)  ⮚ Validate and document the benefit to student (e.g. functional listening evaluation, teacher questionnaires, etc.) and seek audiologist’s advice if problems, concerns arise.  ⮚ Return malfunctioning equipment to PRP or health unit for repair or replacement.  Use Request for Repair form or Equipment Return form provided by PRP.  Return malfunctioning equipment to PRP or health unit for repair or replacement.  Use Request for Repair form or Equipment Return Form provided by PRP.  replacement Notify PRP and clinic by email equipment was sent.  Receive malfunctioning equipment and process repair.  Courier repaired or replaced equipment on following working day to health unit audiologist or school district as requested.  Request to Repair form  Equipment Return formform Year End Inventory Management

Agreement Review. This agreement will be automatically reviewed every three years through a process initiated by the Vancouver Coastal Health Authorityfive years. Parties to this agreement may request a review at any time. Availability Regional Agreement For the Delivery of resources or breakdown in processes are examples Assistive Listening Technology to School Aged Children and Youth Approved and agreed on this date: . On behalf of areas that may trigger a need for review Vancouver Coastal Health Region Schedule 1 - School Districts Within Vancouver Coastal Health Region School District #3893, Richmond Conseil Scholaire Francophone School District #39Administrator, Vancouver School District #44Student Support Services On behalf of non-independent First Nations Schools (FNESC) Director, North Vancouver School District #45Special Education Programs, West Vancouver School District #46FNESC On behalf of Independent Schools of B.C. (Group 1&2) Director of Independent Schools & Homestay On behalf of Provincial Resource Program – Auditory Outreach Superintendent of Schools, Sunshine Coast School District #47, Xxxxxx River School District #48, Xxxx Sound qathet Procedural Responsibilities Vancouver Coastal Health Region for For Delivering Assistive Listening Technology to School Aged Children and Youth Health Unit Audiology Clinic Forms/ Communication School/ School District PRP- Forms/ Communication PRP - Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  ▪ Carry out audiological assessment and diagnostic services  ▪ Get parental approval for audiogram release and report to the school district and PRP  ▪ Health Authority Information Form Release  PRP provides Permission to Share Form  ▪ Collaboration between health unit audiologist and school district personnel regarding classroom environment and support available in school, which may influence the decision regarding the most appropriate assistive listening equipment required to maximize learning.  Determine appropriate channel, including default channel if required.  ▪ Determine most appropriate FM equipment from PRP list of available equipment  ▪ Inform family and provide PRP Permission to Share information form for parent signature PRP Permission to Share form  ▪ Share information with audiologist or technician regarding school and classroom environments, identifying problem areas (e.g. gym—reverberation, possible interference)  environments ▪ Identify competencies needed to support equipment  ▪ Specify who will provide any required in- service.  service ▪ Provide list of available equipment to all public health unitsaudiology clinics, school districts and group 1 and group 2 independent schools  ▪ Loan Bank library Equipment List  ▪ Completes and obtains parent/ guardian signature on PRP Permission to Share form (shared responsibility) ▪ Provide Permission to Share form via website ▪ Provides Permission to Share form ▪ Indicate FM equipment being requested and sign the request form, signaling responsibility for appropriate equipment selection for the student  ▪ Send FM request form, along with audiological information and Permission to Share form to school district for school district administrator signature (except Vancouver Clinic)  FM ▪ Equipment Request form  Complete Permission to Share form if not completed at Health Unit  ▪ Complete and Sign FM request form agreeing to accept financial liability for lost/damaged equipment (district administrator)  ▪ Completes and obtains parent/ guardian signature on PRP Permission to Share form (if audiology clinic hasn’t done so) ▪ Provide FM RM request for support form via Website  Provide Permission to Share form via Website  website ▪ Request for Support Form  Parent Permission to Share form Vancouver health unit only:  ▪ Forward signed forms along with audiological information to PRP  ▪ Send copy of FM RM request form to school district  Place copy of signed FM request form in the child’s public health unit file  Forward signed forms along with audiological information to PRP  Send copy of FM request form to health unit audiology clinic and e-mail when sent to PRP  Update student’s confidential file  ▪ Receive complete Request for Support package  Equipment request form and supporting documentation ▪ Communicate with health unit audiologist if equipment is not available or clarification required  ▪ Discuss options with audiologist and HRT TDHH responsible for the student in the district, if required  Repair form Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  Receive equipment, e-mail confirmation of receipt of shipment to PRP and School District, and complete listening validation  Record in child▪ Update student’s confidential file Send ▪ Update student’s confidential file ▪ Send equipment to public health unit audiology clinic along with equipment service report or packing slip. slip ▪ E-mail health unit audiologist and SD about shipmentSD, equipment has been shipped or if delays anticipated  ▪ Technical Service form Procedural Responsibilities For Delivering Assistive Listening Technology to School Aged Children and Youth (continued) Health Unit Audiology Clinic Forms/ Communication School/ School District Forms/ Communication PRP- Auditory Outreach Forms/ Communication ▪ Receive equipment and complete listening validation ▪ Record in student’s file ▪ Provide shipment tracking info if required ▪ Complete FMRM/HA equipment verification in accordance with best practice, i.e. eletroacoustic FM match with child’s personal hearing aid  practice ▪ Record in child’s file with appropriate documentation  ▪ Arrange for equipment to be sent to student’s HRT TDHH and provide training and/or written material for the use of the equipment and troubleshooting.  troubleshooting ▪ Record when equipment leaves the clinic.  clinic ▪ Pick up equipment at the health unit or receive equipment at a designated location.  location ▪ Equipment validation needs to be conducted by personnel trained to do listening check ▪ Keep note of serial numbered equipment on loan  On request, provide loan/ Packing Slip ▪ Provide annual printout of district equipment currently on loan.  , or by request ▪ Provide training and/or written material to school staff if health unit unable to provide.  ▪ Report loss or damage promptly to PRP ▪ When serial numbered equipment is lost or intentionally damaged beyond repair, the School District or Independent School is expected to cover the cost of replacement ▪ Equipment validation needs to be conducted by personnel trained to do listening checks.  Loss Form ▪ Ensure school principal is aware of the equipment and that security measures are in place.  place ▪ Ensure equipment is listed in the school inventory for insurance purposes ▪ School/ District protocol for equipment security  ▪ Provide ongoing maintenance and equipment checks (e.g. regular listening check, purchase of batteries for the FM equipment and cords as required – School District responsibility to purchase items.)  ▪ Validate and document the benefit to student (e.g. functional listening evaluation, teacher questionnaires, etc.) and seek audiologist’s advice if problems, concerns arise.  arise ▪ Return malfunctioning equipment to PRP or health unit for repair or replacement.  Use Request for Repair form or Equipment Return form provided by PRP.  Return malfunctioning equipment to PRP or health unit for repair or replacement.  Use Request for Repair form or Equipment Return Form provided by PRP.  replacement with documentation and complete forms ▪ Notify PRP and clinic by email equipment was sent.  sent ▪ Receive malfunctioning equipment and process repairrepair or replacement.  ▪ Courier repaired or replaced equipment on following working day within 3 business days to health unit audiologist or school district as requested.  Request to Repair form  requested ▪ Technical Service Form ▪ Equipment Return form

Agreement Review. This agreement will be automatically reviewed every three years through a process initiated by the Vancouver Coastal Health Authorityyears. Parties to this agreement may request a review at any time. Availability of resources or breakdown in processes are examples of areas that may trigger a need for review Vancouver Coastal Health Region Schedule 1 - School Districts Within Vancouver Coastal Northern Health Region School District #3828, Richmond Quesnel School District #3950, Vancouver Haida-Gwaii - Queen Charlotte Islands School District #4452, North Vancouver Prince Rupert School District #4554, West Vancouver Xxxxxxx Valley School District #4657, Sunshine Coast Prince Xxxxxx School District #4759, Xxxxxx Peace River South School District #4860, Xxxx Sound Peace River North School District #81, Fort Xxxxxx School District #82, Coast Mountains School District #87, Stikine School District #91, Nechako Lakes School District #92, Nisga,a Procedural Responsibilities Vancouver Coastal Northern Health Region for Delivering Assistive Listening Technology to School Aged Children and Youth Region Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  Carry out assessment and diagnostic services  Get parental approval for audiogram release and report to the school district and PRP PRP, of equipment is deemed appropriate  Health Authority Information Form Release  PRP provides Permission to Share Form  Collaboration between health unit audiologist and school district personnel regarding classroom environment and support available in school, which may influence the decision regarding the most appropriate assistive listening equipment required to maximize learning.  Determine appropriate channel, including default channel if required.  Determine most appropriate FM from PRP list of available equipment  Inform family and provide PRP Permission to Share information form for parent signature PRP Permission to Share form gain consent .  Share information with audiologist or technician regarding school and classroom environments, identifying problem areas (e.g. gym—reverberation, possible interference)  Identify competencies needed to support equipment  Specify who will provide any required in- in-service.  Provide list of available equipment to all health units, school districts and group 1 and group 2 independent schools  Loan Bank Equipment List  Indicate FM being requested and sign the request form, signaling responsibility for appropriate equipment selection for the student  Send FM request form, along with audiological information and Permission to Share form to school district for completion and school district administrator signature (except Vancouver Clinic)  FM Request form  Complete Permission to Share form if not completed at Health Unit  Complete and Sign sign FM request form agreeing to accept financial liability for lost/damaged equipment (district administrator)  Complete the Permission to Share form  Provide FM request for support form via Website form.  Provide Permission to Share form via Website form.  Request for Support Form  Parent Permission to Share form Vancouver health unit only:  Forward signed forms along with audiological information to PRP  Send copy of FM request form to school district  Place copy of signed FM request form in the child’s health unit file  Forward signed forms along with audiological information to PRP  Send copy of FM request form to health unit and e-mail when sent to PRP  Update student’s confidential file  Receive complete Request request for Support package  Communicate with health unit audiologist if equipment is not available or clarification required  Discuss options with audiologist and HRT responsible for the student in the district, if required  Repair Place copy of signed FM request form in the child’s health unit file  Send equipment to health unit along with equipment service report or packing slip.  E-mail health unit and SD it has been shipped. Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  Receive equipment, e-mail confirmation of receipt of shipment to PRP and School District, and complete listening validation  Record in child’s file Send equipment to health unit along with equipment service report or packing slip. E-mail health unit and SD about shipment, or if delays anticipated  Complete FM/HA equipment verification in accordance with best practice, i.e. eletroacoustic FM match with child’s personal hearing aid  Record in child’s file with appropriate documentation  Arrange for equipment to be sent to student’s HRT and provide training and/or written material for the use of the equipment and troubleshooting.  Record when equipment leaves the clinic.  Pick up equipment at the health unit or receive equipment at a designated location.  Keep note of serial numbered equipment on loan  On request, provide printout of district equipment currently on loan.  Provide training and/or written material to school staff if health unit unable to provide.  Equipment Conduct equipment validation needs to be conducted by personnel trained to do listening checks.  Ensure school principal is aware of the equipment and that security measures are in place.  District protocol for equipment security  Provide ongoing maintenance and equipment checks (e.g. regular listening check, purchase of batteries for the FM and cords as required – School District responsibility to purchase items.)  Validate and document the benefit to student (e.g. functional listening evaluation, teacher questionnaires, etc.) and seek audiologist’s advice if problems, concerns arise.  Return malfunctioning equipment to PRP or health unit for repair or replacement. replacement  Use Request for Repair form or Equipment Return form provided Notify PRP and SD by PRPemail equipment was sent.  Return malfunctioning equipment to PRP or health unit for repair or replacement.  Use Request for Repair form or Equipment Return Form provided by PRP. replacement  Notify PRP and clinic by email equipment was sent.  Receive malfunctioning equipment and process repair.  Courier repaired or replaced equipment on following working day to health unit audiologist or school district as requested.  Request to Repair form  Equipment Return formform Year End Inventory Management Northern Health Region Health Unit School District PRP- Auditory Outreach  Conduct listening check of equipment at end of year.  Send to clinic.  Receive FM equipment from school  Provide Equipment Repair  Conduct listening checks and store functioning equipment until next school year  Provide Equipment Exchange form  Send malfunctioning equipment to PRP for repair or replacement  Conduct summer maintenance on equipment  Ship repaired equipment or replacements to either the health unit or school district, as requested, prior to school startup.  Receive replaced equipment from PRP  Complete FM/HA equipment verification in accordance with best-practices, i.e. electroacoustic FM match with child’s personal hearing aid.  Receive repaired equipment from PRP  Remove equipment from inventory that is not functioning optimally and/or has an unusually high rate of repair.

Agreement Review. This agreement will be automatically reviewed every three years through a process initiated by the Vancouver Coastal Health Authorityyears. Parties to this agreement may request a review at any time. Availability of resources or breakdown in processes are examples of areas that may trigger a need for review Vancouver Coastal Fraser Health Region Schedule 1 - School Districts Within Vancouver Coastal Fraser Health Region School District #3833, Richmond Chilliwack School District #3934, Vancouver Abbotsford School District #4435, North Vancouver Xxxxxxx School District #4536, West Vancouver Surrey School District #4637, Sunshine Coast Delta School District #4740, Xxxxxx River New Westminster School District #4841, Xxxx Sound Burnaby School District #42, Maple Ridge-Pitt Xxxxxxx School District #43, Coquitlam School District #75, Mission School District #78, Fraser-Cascade Procedural Responsibilities Vancouver Coastal Fraser Health Region for Delivering Assistive Listening Technology to School Aged Children and Youth Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  Carry out assessment and diagnostic services  Get parental approval for audiogram release and report to the school district and PRP  Health Authority Information Form Release  PRP Permission to Share form  PRP provides Permission to Share Form  Collaboration between health unit audiologist and school district personnel regarding classroom environment and support available in school, which may influence the decision regarding the most appropriate assistive listening equipment required to maximize learning.  Determine appropriate channel, including default channel if required.  Determine most appropriate FM from PRP list of available equipment  Inform family and provide PRP Permission to Share information form for parent signature PRP Permission to Share form  Share information with audiologist or technician regarding school and classroom environments, identifying problem areas (e.g. gym—reverberation, possible interference)  Identify competencies needed to support equipment  Specify who will provide any required in- service.  Provide list of available equipment to all health units, school districts and group 1 and group 2 independent schools  Loan Bank Equipment List  Indicate FM being requested and sign the request form, signaling responsibility for appropriate equipment selection for the student  Send FM request form, along with audiological information and Permission to Share form to school district for school district administrator signature (except Vancouver Clinic)  FM Request form  Complete Permission to Share form if not completed at Health Unit  Complete and Sign FM request form agreeing to accept financial liability for lost/damaged equipment (district administrator)  Provide FM request for support form via Website  Provide Permission to Share form via Website  Request for Support Form  Parent Permission to Share form Vancouver health unit only:  Forward signed forms along with audiological information to PRP  Send copy of FM request form to school district  Place copy of signed FM request form in the child’s health unit file  Forward signed forms along with audiological information to PRP  Send copy of FM request form to health unit and e-mail when sent to PRP  Update student’s confidential file  Receive complete Request request for Support package  Communicate with health unit audiologist if equipment is not available or clarification required  Discuss options with audiologist and HRT responsible for the student in the district, if required  Place copy of signed FM request form in the child’s health unit file  Update student’s confidential file  Send equipment to health unit along with equipment service report or packing slip.  E-mail health unit and SD, it has been shipped or if delays anticipated  Repair form Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  Receive equipment, e-mail confirmation of receipt of shipment to PRP and School District, and complete listening validation  Record in child’s file Send equipment to health unit along with equipment service report or packing slip. E-mail health unit and SD about shipment, or if delays anticipated  Complete FM/HA equipment verification in accordance with best practice, i.e. eletroacoustic FM match with child’s personal hearing aid  Record in child’s file with appropriate documentation  Arrange for equipment to be sent to student’s HRT and provide training and/or written material for the use of the equipment and troubleshooting.  Record when equipment leaves the clinic.  Pick up equipment at the health unit or receive equipment at a designated location.  Keep note of serial numbered equipment on loan  On request, provide printout of district equipment currently on loan.  Provide training and/or written material to school staff if health unit unable to provide.  Equipment validation needs to be conducted by personnel trained to do listening checks.  Ensure school principal is aware of the equipment and that security measures are in place.  District protocol for equipment security  Provide ongoing maintenance and equipment checks (e.g. regular listening check, purchase of batteries for the FM and cords as required – School District responsibility to purchase items.)  Validate and document the benefit to student (e.g. functional listening evaluation, teacher questionnaires, etc.) and seek audiologist’s advice if problems, concerns arise.  Return malfunctioning equipment to PRP or health unit for repair or replacement.  Use Request for Repair form or Equipment Return form provided by PRP.  Return malfunctioning equipment to PRP or health unit for repair or replacement.  Use Request for Repair form or Equipment Return Form provided by PRP.  replacement Notify PRP and clinic by email equipment was sent.  Receive malfunctioning equipment and process repair.  Courier repaired or replaced equipment on following working day to health unit audiologist or school district as requested.  Request to Repair form  Equipment Return formform Year End Inventory Management Health Unit School District PRP- Auditory Outreach  Conduct listening check of equipment at end of year.  Store in district  Send malfunctioning equipment to PRP for repair or replacement.  Provide Equipment Repair  Provide Equipment Exchange form  Conduct summer maintenance work.  Ship repaired equipment or replacements to either the health unit or school district, as requested, prior to school startup.

Agreement Review. This agreement will be automatically reviewed every three years through a process initiated by the Vancouver Coastal Health Authorityyears. Parties to this agreement may request a review at any time. Availability of resources or breakdown in processes are examples of areas that may trigger a need for review Vancouver Coastal Health Region Schedule 1 - School Districts Within Vancouver Coastal Northern Health Region School District #3828, Richmond Quesnel School District #3950, Vancouver Haida-Gwaii - Queen Charlotte Islands School District #4452, North Vancouver Prince Rupert School District #4554, West Vancouver Xxxxxxx Valley School District #4657, Sunshine Coast Prince Xxxxxx School District #4759, Xxxxxx Peace River South School District #4860, Xxxx Sound Peace River North School District #81, Fort Xxxxxx School District #82, Coast Mountains School District #87, Stikine School District #91, Nechako Lakes School District #92, Nisga,a Procedural Responsibilities Vancouver Coastal Northern Health Region for Delivering Assistive Listening Technology to School Aged Children and Youth Region Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  ⮚ Carry out assessment and diagnostic services  ⮚ Get parental approval for audiogram release and report to the school district and PRP  Health Authority PRP, of equipment is deemed appropriate ⮚ Information Release Form Release  PRP provides Permission to Share Form  ⮚ Collaboration between health unit audiologist and school district personnel regarding classroom environment and support available in school, which may influence the decision regarding the most appropriate assistive listening equipment required to maximize learning.  Determine appropriate channel, including default channel if required.  ⮚ Determine most appropriate FM from PRP list of available equipment  ⮚ Inform family and provide PRP Permission to Share information form for parent signature PRP Permission to Share form  gain consent . ⮚ Share information with audiologist or technician regarding school and classroom environments, identifying problem areas (e.g. gym—reverberation, possible interference)  ⮚ Identify competencies needed to support equipment  ⮚ Specify who will provide any required in- in-service.  ⮚ Provide list of available equipment to all health units, school districts and group 1 and group 2 independent schools  ⮚ Loan Bank Equipment List  ⮚ Indicate FM being requested and sign the request form, signaling responsibility for appropriate equipment selection for the student  ⮚ Send FM request form, along with audiological information and Permission to Share form to school district for completion and school district administrator signature (except Vancouver Clinic)  ⮚ FM Request form  Complete Permission to Share form if not completed at Health Unit  ⮚ Complete and Sign sign FM request form agreeing to accept financial liability for lost/damaged equipment (district administrator)  ⮚ Complete the Permission to Share form ⮚ Provide FM request for support form via Website  form. ⮚ Provide Permission to Share form via Website  form. ⮚ Request for Support Form  ⮚ Parent Permission to Share form Vancouver health unit only:  ⮚ Forward signed forms along with audiological information to PRP  Send copy of FM request form to school district  Place copy of signed FM request form in the child’s health unit file  Forward signed forms along with audiological information to PRP  ⮚ Send copy of FM request form to health unit and e-mail when sent to PRP  Update student’s confidential file  ⮚ Receive complete Request request for Support package  ⮚ Communicate with health unit audiologist if equipment is not available or clarification required  ⮚ Discuss options with audiologist and HRT responsible for the student in the district, if required  Repair ⮚ Place copy of signed FM request form in the child’s health unit file ⮚ Send equipment to health unit along with equipment service report or packing slip. ⮚ E-mail health unit and SD it has been shipped. Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  ⮚ Receive equipment, e-mail confirmation of receipt of shipment to PRP and School District, and complete listening validation  ⮚Record in child’s file Send equipment to health unit along with equipment service report or packing slip. E-mail health unit and SD about shipment, or if delays anticipated  ⮚ Complete FM/HA equipment verification in accordance with best practice, i.e. eletroacoustic FM match with child’s personal hearing aid  ⮚ Record in child’s file with appropriate documentation  ⮚Arrange for equipment to be sent to student’s HRT and provide training and/or written material for the use of the equipment and troubleshooting.  ⮚ Record when equipment leaves the clinic.  ⮚Pick up equipment at the health unit or receive equipment at a designated location.  ⮚Keep note of serial numbered equipment on loan  ⮚On request, provide printout of district equipment currently on loan.  Provide training and/or written material to school staff if health unit unable to provide.  Equipment ⮚ Conduct equipment validation needs to be conducted by personnel trained to do listening checks.  ⮚ Ensure school principal is aware of the equipment and that security measures are in place.  ⮚District protocol for equipment security  ⮚ Provide ongoing maintenance and equipment checks (e.g. regular listening check, purchase of batteries for the FM and cords as required – School District responsibility to purchase items.)  ⮚ Validate and document the benefit to student (e.g. functional listening evaluation, teacher questionnaires, etc.) and seek audiologist’s advice if problems, concerns arise.  ⮚ Return malfunctioning equipment to PRP or health unit for repair or replacementreplacement ⮚ Notify PRP and SD by email equipment was sent.  Use Request for Repair form or Equipment Return form provided by PRP.  ⮚ Return malfunctioning equipment to PRP or health unit for repair or replacement.  Use Request for Repair form or Equipment Return Form provided by PRP.  replacement ⮚Notify PRP and clinic by email equipment was sent.  ⮚ Receive malfunctioning equipment and process repair.  ⮚ Courier repaired or replaced equipment on following working day to health unit audiologist or school district as requested.  ⮚ Request to Repair form  ⮚ Equipment Return formform Year End Inventory Management Northern Health Region

Agreement Review. This agreement will be automatically reviewed every three years through a process initiated by the Vancouver Coastal Health Authority. Parties to this agreement may request a review at any time. Availability of resources or breakdown in processes are examples of areas that may trigger a need for review Vancouver Coastal Health Region Schedule 1 - School Districts Within Vancouver Coastal Health Region School District #38, Richmond School District #39, Vancouver School District #44, North Vancouver School District #45, West Vancouver School District #46, Sunshine Coast School District #47, Xxxxxx River School District #48, Xxxx Sound Procedural Responsibilities Vancouver Coastal Health Region for Delivering Assistive Listening Technology to School Aged Children and Youth Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  ⮚ Carry out assessment and diagnostic services  ⮚ Get parental approval for audiogram release and report to the school district and PRP  ⮚ Health Authority Information Form Release  ⮚ PRP provides Permission to Share Form  ⮚ Collaboration between health unit audiologist and school district personnel regarding classroom environment and support available in school, which may influence the decision regarding the most appropriate assistive listening equipment required to maximize learning.  ⮚ Determine appropriate channel, including default channel if required.  ⮚ Determine most appropriate FM from PRP list of available equipment  ⮚ Inform family and provide PRP Permission to Share information form for parent signature PRP Permission to Share form  ⮚ Share information with audiologist or technician regarding school and classroom environments, identifying problem areas (e.g. gym—reverberation, possible interference)  ⮚ Identify competencies needed to support equipment  ⮚ Specify who will provide any required in- service.  ⮚ Provide list of available equipment to all health units, school districts and group 1 and group 2 independent schools  ⮚ Loan Bank Equipment List  ⮚ Indicate FM being requested and sign the request form, signaling responsibility for appropriate equipment selection for the student  ⮚ Send FM request form, along with audiological information and Permission to Share form to school district for school district administrator signature (except Vancouver Clinic)  ⮚ FM Request form  ⮚ Complete Permission to Share form if not completed at Health Unit  ⮚ Complete and Sign FM request form agreeing to accept financial liability for lost/damaged equipment (district administrator)  ⮚ Provide FM request for support form via Website  ⮚ Provide Permission to Share form via Website  ⮚ Request for Support Form  ⮚ Parent Permission to Share form Vancouver health unit only:  ⮚ Forward signed forms along with audiological information to PRP  ⮚ Send copy of FM request form to school district  ⮚ Place copy of signed FM request form in the child’s health unit file  ⮚ Forward signed forms along with audiological information to PRP  ⮚ Send copy of FM request form to health unit and e-mail when sent to PRP  ⮚ Update student’s confidential file  ⮚ Receive complete Request for Support package  ⮚ Communicate with health unit audiologist if equipment is not available or clarification required  ⮚ Discuss options with audiologist and HRT responsible for the student in the district, if required  ⮚ Repair form Health Unit School District PRP- Auditory Outreach Forms/ Communication Forms/ Communication Forms/ Communication  ⮚ Receive equipment, e-mail confirmation of receipt of shipment to PRP and School District, and complete listening validation  ⮚Record in child’s file Send ⮚Send equipment to health unit along with equipment service report or packing slip. E-mail health unit and SD about shipment, or if delays anticipated  ⮚ Complete FM/HA equipment verification in accordance with best practice, i.e. eletroacoustic FM match with child’s personal hearing aid  ⮚ Record in child’s file with appropriate documentation  ⮚Arrange for equipment to be sent to student’s HRT and provide training and/or written material for the use of the equipment and troubleshooting.  ⮚ Record when equipment leaves the clinic.  ⮚Pick up equipment at the health unit or receive equipment at a designated location.  ⮚ Keep note of serial numbered equipment on loan  ⮚ On request, provide printout of district equipment currently on loan.  ⮚ Provide training and/or written material to school staff if health unit unable to provide.  ⮚ Equipment validation needs to be conducted by personnel trained to do listening checks.  ⮚ Ensure school principal is aware of the equipment and that security measures are in place.  ⮚District protocol for equipment security  ⮚ Provide ongoing maintenance and equipment checks (e.g. regular listening check, purchase of batteries for the FM and cords as required – School District responsibility to purchase items.)  ⮚ Validate and document the benefit to student (e.g. functional listening evaluation, teacher questionnaires, etc.) and seek audiologist’s advice if problems, concerns arise.  ⮚ Return malfunctioning equipment to PRP or health unit for repair or replacement.  ⮚ Use Request for Repair form or Equipment Return form provided by PRP.  ⮚ Return malfunctioning equipment to PRP or health unit for repair or replacement.  ⮚ Use Request for Repair form or Equipment Return Form provided by PRP.  ⮚ Notify PRP and clinic by email equipment was sent.  ⮚ Receive malfunctioning equipment and process repair.  ⮚ Courier repaired or replaced equipment on following working day to health unit audiologist or school district as requested.  ⮚ Request to Repair form  ⮚ Equipment Return formform Year End Inventory Management Health Unit School District PRP- Auditory Outreach ⮚ Store at health unit (districts #38, 39, 44, 45) ⮚ Send malfunctioning equipment to PRP for repair or replacement. ⮚ Conduct listening check of equipment at end of year. ⮚ Store in district (districts # 46,47,48) ⮚ Send malfunctioning equipment to PRP for repair or replacement. ⮚ Provide Equipment Repair ⮚ Provide Equipment Exchange form ⮚ Provide Accessories form ⮚ Conduct summer maintenance work. ⮚ Ship repaired equipment or replacements to either the health unit or school district, as requested, prior to school startup. ⮚ Receive repaired equipment from PRP ⮚ Receive replaced equipment from PRP if matching required ⮚ Receive repaired equipment from PRP (districts #46,47,48) ⮚ Remove equipment from inventory that is not functioning optimally and/or has an unusually high rate of repair.